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A   TREATISE 


ON 


Orthopedic  Surgery 


EDWARD   H.   BRADFORD,  M.D., 

Surgeon   to   the   Children's   Hospital,    Boston   City   Hospital,   and    Samaritan   Hospital ; 
Instructor  in  Clinical  Surgery,  Harvard  Medical  School; 


AND 


ROBERT  W.  LOVETT  M.D., 

Surgeon   to   the   Samaritan   Hospital;    Assistant   Out-Patient   Surgeon    to   the   Children's   Hospital: 

Out-Patient  Surgeon  to  the  Carney  Hospital ;    formerly  Assistant  Surgeon  to  the  New 

York  Orthopedic  Dispensary  and  Hospital. 


ILLUSTRATED   WITH    789   WOOD   ENGRAVINGS. 


NEW  YORK 

WILLIAM    WOOD    &    COMPANY 

1S90 


Copyrighted,  1890, 
WILLIAM  WOOD  &  COMPANY. 

/,-  S~SQ 


ELECTROTYPED   AND    PRINTED   BY 

THE   publishers'    PRINTING  COMPANY 

30    &    32    WEST    13TH    STREET 

NEW    YORK 


PREFACE 


The  writers  of  previous  works  on  Orthopedic  Surgery  have  con- 
fined themselves  to  a  consideration  of  the  treatment  of  existing 
deformities,  such  as  club-foot,  lateral  curvature,  and  bow  legs.  The 
only  conspicuous  exception  to  this  is  found  in  the  excellent  book 
of  Dr.  Sayre.  But  the  term  Orthopedic  Surgery,  if  it  is  properly 
defined,  should  include  the  prevention  as  well  as  the  cure  of  de- 
formity. For  this  reason  the  diseases  of  the  joints  have  been  con- 
sidered by  us  at  considerable  length,  inasmuch  as  they  are  among 
the  most  common  sources  of  deformity  and  disability. 

We  have  endeavored  throughout  to  include  such  subjects  as  are 
likely  to  come  to  the  attention  of  those  who  interest  themselves  in 
the  practice  of  this  branch  of  surgery,  without  perhaps  adhering 
too  closely  to  the  definition  of  the  term  orthopedic  surgery.  In 
this  way,  besides  the  consideration  of  joint  disease  and  Pott's  dis- 
ease, we  have  added  a  brief  description  of  some  disabling  and  de- 
forming nervous  affections,  which  we  have  only  attempted  to  dis- 
cuss in  their  practical  surgical  aspect.  The  deformities  resulting 
from  fractures,  dislocations,  and  burns  are  so  fully  treated  in 
works  on  general  surgery  that  they  have  not  been  considered  here. 

Edward  H.  Bradford. 
Robert  \V.  Lovett. 

Boston,  May  15th,  iSgo. 


TABLE  OF  CONTENTS. 


PACE 

Preface, ■  .        .        .  iii 

CHAPTER  I. 

Pott's  Disease. 

Definition. — History. — Pathological  Anatomy. — Occurrence  and  Eti- 
ology.—  Symptoms. —  Diagnosis.  —  Differential  Diagnosis.  — Prog- 
nosis.— Treatment 1-102 

CHAPTER  II. 

Lateral  Curvatures  of  the  Spine. 

Definition.— Frequency.— Predisposition  as  to  Sex.— Clinical  History. — 
Stages  of  the  Aftection. — Symptoms. — Pains. — Distortion. — Cur\^a- 
ture. — Torsion. — Varieties  of  Lateral  Curvature. — Etiology. —  Path- 
ology.—  Diagnosis.  —  Prognosis.  —  Preventive  Measures.  —  Treat- 
ment,        .         .   103-183 

CHAPTER  III. 

Other  Affections  of  the  Spine. 

Curvatures  of  the  Spine. —  Physiological  Curvatures. — Scoliosis. — 
Kyphosis. — Round  Shoulders. — Rheumatism  of  the  Spine. — Lor- 
dosis.— Weak  Spine. — Spondylolisthesis. — Affections  of  the  Tho- 
rax.— Malignant  Disease  of  the  Spine, 184-201 

CHAPTER  IV. 
The  Pathology  of  Chronic  Joint  Disease. 

Diseases  Affecting  the  vSynovial  Membrane  ;  Anatomy  of  Sj'novial 
Membranes ;  Chronic  Serous  Synovitis  ;  Chronic  Purulent  Syno- 
vitis.— II.  Jomt  Diseases  Affecting  the  Cartilage;  Hypertrophy 
and  Atrophy;  Primary  Inflammation  of  Cartilage;  Secondar\- 
Inflammation  of  Cartilage  ;  Loose  Bodies  in  the  Joints. — III.  Joint 
Diseases  beginning  in  Bone ;  Tuberculous  Ostitis ;  Gummatous 
Ostitis ;  Formative  Ostitis  (Arthritis  Deformans)  ;  Exostoses  ; 
Tumors  of  the  Joints;  Miscellaneous  Minor  Affections  of  the 
Bone. — IV.  Joint  Diseases  beginning  m  the  Peri-articular  Struc- 


vi  TABLE   OF   CONTENTS. 

I'AGK 

tures;  Ligamentous  Afifections  ;  Peri-articular  Abscess  ;  Bursitis — 

other  Affections  Impairing  Joints,      .......  202-230 

CHAPTER  V. 
The  Etiology,  Course,  and  Termination  of  Chronic  Joint  Disease. 

Etiology. — Chronic  Serous  Synovitis.— Chronic  Purulent  Synovitis. — 
Inflammation  of  Cartilage. — Joint  Manifestations  in  {a)  Tubercu- 
losis, (b)  Syphilis,  {c)  Rheumatism,  (d)  Arthritis  Deformans,  {e)  Gout, 
(/)  Acute  Infectious  Diseases,  {g)  Miscellaneous  Conditions. — 
Tabes  Dorsalis. — Haemophilia. — Growing  Pains. — Acute  Arthritis 
in  Infants. — The  Distribution  of  Chronic  Joint  Disease. — Course 
and  Termination  of  Chronic  Joint  Disease.^Ankylosis. — Treat- 
ment of  Chronic  Joint  Disease, 231-254 

CHAPTER  VI. 
Hip  Disease. 

Definition. — Pathology. — Clinical  History.— Diagnosis. —  Differential 

Diagnosis. — Prognosis. — Treatment  (Conservative — Operative),      .  255-359 

CHAPTER  VII. 

Other  Diseases  of  the  Hip-Joint. 

Chronic  Synovitis. — Symptoms. — Diagnosis. —  Treatment. — Arthritis 
Deformans. — Pathology  and  Etiology. — Symptoms. — Diagnosis. — 
Treatment. — Charcot's  Diseases  of  the  Hip-Joint. — The  Acute 
Arthritis  of  Infants. — Syphilitic  Disease  of  the  Hip. — Periostitis  of 
the  Hip. — Malignant  Disease  of  the  Hip. — Loose  Cartilages  in  the 
Hip-Joint. — Interstitial  Absorption  of  the  Neck  of  the  Femur,       .  360-365 

CHAPTER  VIII. 
Tumor  Albus  of  the  Knee-Joint. 

Definition. — Pathology. — Clinical  History. — Diagnosis. — Differential 
Diagnosis. — Prognosis. — Treatment,  («)  Conservative,  {B)  Operative 
(Excision — Arthrectomy — Amputation), 366-397 

CHAPTER  IX. 
Other  Diseases  of  the  Knee-Joint. 

Chronic  Synovitis. — Intermittent  Hydrops  Articulorum. — Arthritis 
Deformans. — Loose  Bodies  in  the  Knee-joint. — Internal  Derange- 
ment of  the  Knee-joint. — Bursitis. — Cysts  about  the  Knee-joint. 
— Charcot's  Disease. — Dislocation  of  the  Patella. — Primary  Dis- 
ease of  the  Cartilages. — Rupture  of  the  Patella  Tendon,  .         .  398-417 

CHAPTER  X. 

Diseases  of  the  Joints  of  the  Ankle  and  Foot. 

Diseases  of  the  Ankle-joint. — Simple  Synovitis  and  Ostitis. — Symp- 
toms.— Diagnosis. — Treatment. — ^  Arthritis  Deformans. —  Diseases 
of  the  Scapho-cuneiform  Articulation. — Diseases  of  Metatarso- 
phalangeal Articulation. — Bursitis  of  the  Ankle,       .         .         .         .418-428 


TABLE  OF  CONTENTS.  vii 

PACE 

CHAPTER  XI. 

Diseases  of  'vwv.  Siioui.dick,  Eeijovv,  and  Wrist  JfjiNTS. 

Shoulder-Joint. — Acute  Synovitis. — Chronic  Serous  Synovitis. — Os- 
titis.—Chronic  Rheumatoid  Arthritis. — Periarthritis. —  Charcot's 
Disease. — Synovial  Cysts  and  Bursse. — Treatment  of  Shoulder-Joint 
Diseases. — Elbow-Joint.-— Synovitis.— Ostitis. —  Chronic  Rlicuma- 
toid  Arthritis. — Urethral  Arthritis. — Charcot's  Disease. — .Syphilitic 
Disease. — Peri-articular  Disease  and  Stiffness  of  the  Elbow. — 
Treatment  of  Elbow-Joint  Diseases. — Diseases  of  the  Wrist-Joint. 
— Ostitis. — Teno-Synovitis. — Rheumatoid  Arthritis. — Treatment  of 
Wrist-Joint  Disease 429-444 

CHAPTER  XH. 

Diseases  of  the  Sacro-Iliac  and  other  Joints. 

Diseases  of  the  Sacro-Iliac  Joint. — Diseases  of  the  Phalangeal  Articu- 
lations.— Diseases  of  the  Temporo-Maxillary  Articulation. — Dis- 
eases of  the  Sterno-Clavicular  and  Acromio-Clavicular  Joints. — 
Diseases  of  the  Articulation  between  the  Pieces  of  the  Sternum. — 
Diseases  of  the  Sacro-Coccygeal  Joints. — Diseases  of  the  Sym- 
physis Pubis, 445-449 

CHAPTER  XIII. 

Club-Foot. 

Frequency. — Anatomy. — Causation. — Symptoms. — Diagnosis. —  Prog- 
nosis.— Treatment, 450-508 

CHAPTER  XIV. 

Congenital  Dislocations. 
Congenital  Dislocations. — Occurrence. — Congenital  Dislocation  of  the 
Hip.—  Frequency  and  Occurrence. — Etiology. — Pathology. — Symp- 
toms.— Diagnosis. —  Differential     Diagnosis.—  Prognosis. —  Treat- 
ment.— Congenital  Dislocations  of  other  Joints  than  the  Hip,         .  509-526 

CHAPTER  XV. 

Congenital  Deformities  of  the  Fingers  and  Toes. 
Club-Hand. — Supernumerary  Digits. — Deficiency  of  the  Fingers  and- 
Toes.— Hypertrophy  of  the  Fingers  and  Toes.— Webbed  Fingers 
and  Toes. — Congenital  Contractions  and  Tumors  of  the  Digits,     .  527-537 

CHAPTER  XVI. 

Infantile  Spinal  Paralysis. 
Definition. — History. — Etiology.—  Pathology. —  Symptoms. —  Diagno- 
sis.— Differential  Diagnosis. — Prognosis. — Treatment,      .         .         .  538-577 

CHAPTER  XVII. 
Cerebral  Paralysis  of  Children. 
Symptoms.  —  Hemiplegia.  —  Spastic    Paralysis.  —  Incoordination     of 
Idiocy— Etiology  of   Cerebral    Paralysis. — Patholog}^   of   Cerebral 
Paralysis.- -Diagnosis. — Differential  Diagnosis.— Prognosis.— Treat- 
ment  '"    , 578-599 


viii  TABLE   OF   CONTENTS. 

PAGE 

CHAPTER  XVIII. 

Pseudo-Hypertrophic  and  other  Paralyses. 

Pseudo-Hypertrophic     Muscular    Paralysis.  —  Progressive     Muscular 

Atrophy. — Hereditary  Ataxia, 600-611 

CHAPTER  XIX. 

Rickets. 

Definition. —  Pathological  Anatomy. —  Occurrence  and  Etiology. — 
Symptoms.  —  Diagnosis.  —  Differential  Diagnosis.  —  Prognosis.  — 
Treatment, 612-638 

CHAPTER  XX. 

Knock-Knee  and  Bow  Legs. 

Knock-Knee. — Occurrence  and  Etiology. — Symptoms. — Diagnosis. — 
Prognosis. — Treatment. —  Expectant. —  Mechanical. —  Operative. — 
Bow  Legs. — Occurrence. —  Causation.  —  Symptoms.  —  Diagnosis. — 
Prognosis. — Treatment. — Expectant. —  Mechanical. — Operative,      .  639-690 

CHAPTER   XXI. 

Torticollis. 

Definition. —  Etiology. —  Varieties. —  Pathological  Anatomy. —  Symp- 
toms.— Diagnosis. — Prognosis. — Treatment. — Mechanical. — Opera- 
tive,         691-71 1 

CHAPTER  XXII. 

Unilateral  Atrophy  and  Hypertrophy. 
Atrophy  and  Hypertrophy, 712-714 

CHAPTER  XXIII. 

Dupuytren's  Contraction  of  the  Fingers. 

Definition. — History. — Pathology. — Etiology  and  Occurrence. — Symp- 
toms.— Diagnosis. — Prognosis. — Treatment, 715-726 

CHAPTER  XXIV. 

Flat-Foot  and  other  Affections  of  the  Feet. 

Talipes  Valgus.— Congenital  Talipes  Valgus. — Acquired  Valgus. — 
Varieties  and  Frequency. — Causation. — Pathological  Anatomy. — 
Symptoms. — Diagnosis. — Prognosis. —  Treatment. —  Talipes  Equi- 
nus. — Non-Deforming  Club-Foot. — Talipes  Calcaneus. — PesCavus. 
— Deformities  of  the  Toes. — Hallux  Valgus. — Hallux  Varus. — 
Hallux  Rigidus. — Hammer  Toe. — Deviations  of  the  Small  Toes. — 
Morton's  Painful  Affection  of  the  Foot. — Teno-Synovitis. — Other 
Minor  Afl'ections, 727-760 

CHAPTER  XXV. 

Functional  Affections  of  the  Spine  and  Limbs. 

Definition. — Etiology. — Frequency. — Occurrence. — Symptoms. — Spine. 

— Hip. — Knee. — Diagnosis. — Prognosis. — Treatment,       .         .         .  761-773 


ORTHOPEDIC   SURGERY. 


CHAPTER  I. 

POTT'S    DISEASE. 


Definition. — History. — Pathological  Anatomy. — Occurrence    and    Etiolog)'. — 
Symptoms. — Diagnosis. — Dififerential  Diagnosis. — Prognosis — Treatment. 

Definition. —  Pott's  Disease  is  the  name  applied  to  a  pathological 
process  which  attacks  the  bodies  of  the  vertebrae.  This  disease 
was  first  clearly  described  by  Percival  Pott  in  1779,  and  in  recogni- 
tion of  this  fact  it  is  now  commonly  called  by  his  name.  The  other 
names  by  which  the  affection  is  known  are  as  follows :  Spondy- , 
litis,  Malum  Pottii,  caries  of  the  spine,  kyphosis,  angular  curvature, 
and  spinal  curvature.  In  German  it  is  known  as  Die  Potfsche 
Kyphose,  Spitzbuckel^  and  Winkclforniige  Knicknng  der  Wirbelsdulc; 
in  French  as  cypJwse,  and  inal  de  Pott. 

History. — Antero-posterior  curvature  of  the  spine  is  an  affection 
which  Was  described  by  the  ancients,  and  was  known  to  Hippo- 
crates and  Galen,  who  attributed  its  cause  to  tubercle  "  within  and 
without  the  lungs."  Ambroise  Pare  wrote  of  it  and  used  a  metal 
cuirass  in  its  treatment,  but  it  was  not  until  the  time  of  Perci\^al 
Pott  that  any  accurate  description  of  the  disease  was  given.'  In 
honor  of  that  surgeon  the  disease  is  chiefly  known  by  his  name. 
The  existence  of  the  disease  in  prehistoric  times  in  North  America 
is  evidenced  by  the  picture  of  a  specimen  from  the  Peabody  i\Iu- 
seum,  Cambridge,  Mass. 

Pathological  Anatomy. 

Pott's  Disease  represents  the  result  cjf  a  destructive  ostitis  affect- 
ing the  sporigy  tissue  of  one  or  more  of  the  vertebral  bodies.  This 
ostitis  is    tuberculous    in    type    and    follows  the    same    course    as 

*  Pott,  "Remarks  on  that  Kind  of  Palsy  Affecting  the  Lovver'Limbs,"  et-c.,  London,  1779, 

I 


2  ORTHOPEDIC  SURGERY. 

tuberculous  ostitis  occurring  at  the  epiphyses  of  the  long  bones, 
as  in  hip  disease,  tumor  albus,  etc. 

A  detailed  account  of  the  histological  character  of  tuberculous 
ostitis  will  .be  given  in  Chapter  IV.  Nothing  more  than  a  very 
brief  account  of  the  process  as  it  occurs  in  this  especial  region  will 
be  attempted  here. 

The  first  appearance  noticeable  to  the  naked  eye  on  examining 
a  section  of  a  diseased  vertebra  at  an  early  stage  of  the  disease,  is 
.a  small  hypersemic  spot  in  some  part  of  the  spongy  portion  of  the 


S'^ 


Fir.  I. — Pott's  Disease  Involving  the  whole  Dorsal  Region.     Prehistoric  Indian  Remains.     (Peabody 
Museum,  Spec.  17,223.) 


body  of  the  vertebra,  generally  near  the  anterior  surface  of  the 
body.  This  spot  grows  larger  and  more  red  as  the  process  ex- 
tends, and  finally  the  centre  becomes  opaque  and  grayish,  while 
a  zone  of  hyperaemia  surrounds  it.  A  focus  of  tuberculous  osti- 
tis is  present.  If  this  process  extends,  the  opaque  spot  becomes 
larger,  and  finally  cheesy  degeneration  of  its  centre  takes  place. 
At  other  times  both  caseation  .and  degeneration  into  pus  take 
place,  and  a  localized  abscess  of  bone  exists,  probably  encapsul- 
ated in  a  membrane  of  inflammatory  tissue,  which  surrounds  the 
focus,  endeavoring  to  protect  the  surrounding  healthy  bone  from 


J'OTT'S  DISEASE.  3 

the  erosive  action  of  the  focus.  Microscopical  examination  shows 
a  mass  of  tubercles  in  a  rarefied  sponj^^y  bone  tissue,  and  in  the 
tubercles  are  to  be  found  tubercle  bacilli.  From  the  fact  that 
these  characteristics  are  to  be  found  in  nearly  all  the  specimens 
examined,  the  affection  is  spoken  of  as  tuberculous  ostitis. 

The  focus  of  caseous  material  may  either  be  absorbed  or  calci- 
fied, or,  as  happens  much  more  commonly,  the  ostitis  may  increase 
until  it  has  destroyed  a  large  part  or  the  whole  of  a  vertebral  body. 
In  its  course  of  enlargement  it  includes  portions  of  bone,  the  nutri- 
tion of  which  is  cut  off  by  the  adjacent  inflammatory  destruction. 
These  portions  necessarily  become  necrosed  and  with  caseous  mat- 
ter, granulation  tissue,  and  the  products  of  inflammation  constitute 
an   area   of   altered   structure   in   the  vertebral   body.     If  this  dis- 


FiG.  2. — Bone  Sequestrum. 


Fig.  4. 

Destruction  of  Part  of  Two  Vertebrae 
with  Consequent  Deformity. 


Fig.  5. — Cheesy  focus  in  the  Body  of 

a  Vertebra,  showing  also  Patency 

of  Spinal  Canal.  (Schreiber.) 


eased  area  has  become  large  enough,  the  vertebral  body  gradually 
becomes  incapable  of  sustaining  as  much  pressure  as  before. 
From  the  peculiar  weight-bearing  function  of  the  vertebral  column 
the  pressure  upon  each  vertebral  body  is  always  considerable  when 
the  vertebral  column  is  in  the  erect  position.  If  one  vertebral 
body  is  becoming  excavated,  a  point  will  be  reached  where  it  can 
no  longer  sustain  the  weight  but  must  give  way  slowly  or  suddenly. 
A  forward  tilt  of  the  whole  vertebral  column  above  the  seat  of 
disease  is  then  inevitable,  with  a  certain  amount  of  backward 
angular  deformity  at  the  diseased  vertebra.  This  is  the  mechanism 
of  the  production  of  the  knuckle  in  the  back.  It  is,  in  brief,  a  soft- 
ening and  destruction  of  one  or  more  vertebral  bodies,  and  a  giving 
way  of  the  column  at  that  point. 

This  process  is  limited,  as  a  rule,  to  the  vertebral  bodies;    the 
transverse,  articular,  or  spinous  processes  are  rarely  affected  sec- 


ORTHOPEDIC  SURGERY. 


ondarily,  and,  so  far  as  is  known,  never  primarily,  their  structure  of 
hard  bone  apparently  protecting  them  from  tubercular  invasion. 

The  disease  is  therefore  in  no  sense  an  articular  affection,  al- 
though pathologically  it  resembles  the  epiphyseal  and  juxta-epiphy- 
seal  ostitis  classed  among  the  joint  diseases.  There  has  been 
much  discussion  as  to  the  possibility  of  primary  tubercular  disease 
of  the  intervertebral  cartilage,  some  authorities  affirming  its  impos- 
sibility, and  denying  the  reliability  of  the  pathological  observations 


Fig.  6.- 


-Spinal  Column  in  Well-marked  Caries  of 
Spine.     (Warren  Museum.) 


Fig.  7.— Primary  Disease  of  Two  Different 
Parts  of  Spinal  Column. 


cited  as  proof  to  the  contrary.  The  facts  are,  that  the  interverte- 
bral cartilage  is  absorbed  at  an  early  stage  in  the  disease,  but  that 
a  few  cases  have  been  reported  by  reliable  observers  in  which  there 
would  appear  to  be  no  doubt  that  the  cartilage  alone  was  affected, 
as  has  been  observed  in  a  few  rare  instances  of  primary  disease  of 
the  semilunar  cartilages  of  the  knee-joint. 

Various  portions  of  the  vertebral  bodies  may  be  affected.  There 
may  be  two  or  more  foci  in  one  vertebra,  or  the  whole  body  may 
be  equally  affected;    the  disease  may  be  limited  to  one  spot,  form- 


POTTS  DISEASE. 


5 


ing  a  local'ized  abscess  of  the  bone,  or  it  m-ay  extend  so  as  to  in- 
volve the  adjacent  vertebrae.  Primary  disease  of  two  vertebral 
bodies  in  different,  non  adjacent  parts  of  the  spine  is  rare,  though 
it  has  been  recorded.  But  an  extensive  destruction  of  many  ad- 
jacent vertebrae  from  primary  disease  of  one  may  be  said  to  be 
the  rule  in  Pott's  disease.  In  some  instances  this  destructive  pro- 
cess may  be  limited  to  the  surfaces  of  a  large  number  of  vertebral 
bodies:  in  others  a  few  contiguous  vertebral  bodies  are  completely 
destroyed.  The  number  of  vertebrje  involved  necessarily  varies; 
in  some  instances  the  bodies  of  twelve  or  even  more  have  been 


Tig.  8.— Pott's  Disease  with  Two  Foci  of  Dis- 
ease, Dorsal  and  Lumbar. 


Fig.  9. — Extensive  Dorsal  Caries  Causing  Large 
Angular  Deformity. 


destroyed,  producing  a  deformity  which  involves  almost  the  whole 
of  the  spinal  column.  A  superficial  ostitis  of  the  anterior  surfaces 
of  the  bodies,  without  involving  the  inter-vertebral  cartilages  or 
impairing  the  Aveight-bearing  function  of  the  vertebrae,  has  been 
observed,  though  it  is  rare. 

In  certain  cases  the  formation  of  pus  is  a  characteristic  of  the 
disease  from  the  first,  and  in  these  cases  abscesses  are  apt  to  be  a 
conspicuous  feature.  The  pus  finds  its  way,  after  the  destruction 
of  the  body  of  the  vertebra,  into  the  surrounding  tissues  and  gravi- 
tates downward.  It  appears  usually  in  the  course  of  the  sheath  of 
the  psoas  muscle  when  the  disease  is  situated  in  the  lower  half  of 
the  spine,  but  the  site  of  the  abscess  necessarily  depends  upon  the 
place  of  the  original  disease,  and  may  be  in  the  mouth — as  in  re- 


OR  THOPEDIC  S  URGER  V. 


tro-pharyngeal  abscess — in  the  neck,  in  the  axilla,  or  in  the  back, 
lungs,  abdomen,  or  groin. 

In  certain  cases  meningitis  and  myelitis  are  present  in  the  cord 
opposite  the,  seat  of  disea.se,  accompanied  sometimes  by  what  is 
virtually  the  destruction  of  the  cord  at  that  point. 

The  pathological  condition  of  the  spinal  cord  and  its  membranes 
in  the  paralysis  accompanying  Pott's  disease  of  the  spine  has  been 
well  described  by  Charcot,  Michaud,  Courjon,  Echeverria,  and 
others.  It  has  been  shown  by  these  writers  that  the  paralysis  is 
very  rarely  caused  by  direct  pressure  of  bone,  as  it  is  uncommon 

for  even  very  marked  deformi- 
ties of  the  spine  to  narrow  the 
spinal  canal  to  any  great  ex- 
tent. Moreover,  paralysis  some- 
times occurs  before  there  is  any 
deformity,  and  it  often  recov- 
ers while  the  deformity  gets 
worse.  Many  cases  with  ex- 
treme deformity  are  never  par- 
alyzed at  all.  Autopsy  shows 
that  in  cases  of  paralysis  the 
process  ordinarily  begins  as  an 
external  pachymeningitis.  The 
caries  of  the  vertebrae,  by  con- 
tiguity or  by  irritation,  causes 
this  meningitis,  and  there  is  a 
deposit  of  inflammatory  mate- 
rial in  the  dura,  a  consequent 
thickening  of  that  membrane, 
and  compression  of  the  cord  by 
this  thickened  dura  at  the  point 
of  irritation.  The  compression  probably  at  once  starts  a  myelitis, 
and  it  is  this  myelitis  that  is  the  cause  of  the  paralysis.  As  the 
seat  of  the  caries  is  in  the  bodies  of  the  vertebrae,  the  meningitis  is 
ordinarily  anterior,  and  the  myelitis  is  most  severe  in  that  part  of 
the  cord,  especially  at  first,  but  it  varies  in  extent  from,  a  mere  infil- 
tration to  a  complete  disintegration  of  the  cord.  It  may  be  more 
or  less  unilateral,  it  may  extend  up  or  down  the  cord,  but  pres- 
sure-myelitis causes  the  paralysis,  which  will  vary  with  the  extent 
and  seat  of  the  lesion.  Ascending  and  descending  secondary 
degenerations  follow  in  time,  when  it  is  of  any  considerable  ex- 
tent. If  the  myelitis  ceases,  it  leaves  a  certain  amount  of  scle- 
rosis of  the  cord  at  the  seat  of  the  disease.  This,  again,  may  be 
very  slight,  or  the  cord  may  be  reduced  to  a  fraction  of  its  for- 


FiG.    lo. — Patency   of  Spinal   Canal-  in   Pronounced 
Caries  of  Spine.     (Warren  Museum.) 


POTT'S  J)  IS  EASE.  y 

mer  size,  and  yet  serve  well  enough  to  transmit  healthy  nervous 
impulses. 

But  meningitis  is  not  the  only  cause  of  coini^ression-myelitis  in 
this  disease,  although  it  is  the  common  one.  There  may  be  a 
direct  strangulation  of  the  cord  by  the  vertebral  arches,  obliterat- 
ing the  canal;  or  an  abscess  from  carious  bone  may  be  a  source  of 
pressure  within  the  canal.  A  caseous  deposit  from  the  vertebrae 
and  a  loose  piece  of  bone  have  been  found  as  sources  of  pressure. 
From  the  autopsies  it  seems  probable  that  pressure  from  any  source 
at  once  gives  rise  to  a  mild  myelitis. 

Dr.  Elliot  has  made  a  most  careful  pathological  and  experimental 
study  of  the  pressure  paralysis  of  Pott's  disease,  and  has  reached 
the  following  conclusions :  that  the  lesion  begins  as  a  simple  me- 
chanical pressure  on  the  cord  in  the  form  of  abscess  products, 
thickened  dura,  or  bone,  that  the  inflammatory  process  in  the  dura 
is  a  limited  one,  and  that  the  medullary  surface  of  the  dura  is 
almost  always  normal.  As  there  is  no  tendency  of  the  cord  to  be 
involved  by  the  specific  carious  process  going  on  in  the  bone,  the 
cord  lesion  is  purely  the  result  of  pressure. 

That  the  presence  of  sclerotic  tissue  at  the  site  of  the  cord  lesion 
in  cases  of  long  standing  is  not  an  evidence  that  the  process  was 
originally  an  inflammatory  one,  and  experimental  physiology  gives 
no  evidence  of  an  inflammatory  lesion  following  experimental  com- 
pression of  the  cord.  And  pathological  findings  in  recent  cases 
reveal  but  few  instances  where  the  original  lesion  seems  to  have 
been  inflammatory.  In  short,  his  research  would  lead  to  the  con- 
clusion that  the  original  cord  lesion  is  not,  as  a  rule,  inflammatory.' 

Fig.  1 1  (from  Gowers)  shows  a  series  of  sections  of  the  spinal  cord  at 
different  levels  in  a  case  of  pressure  myelitis  from  caries  of  the  spine. 

In  proportion  to  the  extent  of  the  disease  and  the  number  of 
vertebrae  involved,  an  angular  deformity  of  the  spine  may  be  pres- 
ent to  any  extent.  In  severe  cases  this  angular  deformity  leads  to 
many  secondary  pathological  changes.  The  shape  and  capacity  of 
the  chest  is  necessarily  very  much  altered,  and  the  ribs  sometimes 
sink  into  the  pelvis.  A.s  a  result  of  these  changes  in  chest  capac- 
ity, hypertrophy  of  the  heart,  often  accompanied  by  valvular  dis- 
ease, is  common.  In  examining  thirty-one  post-mortem  specimens 
of  Pott's  disease  in  adults,  Neidert^  found  hypertrophy  of  the 
heart  in  twenty-four,  muscular  degeneration  of  the  walls  of  the 
heart  in  four,  and  mitral  stenosis  in  two.  Lannelongue^  found  a 
very  marked  narrowing  of  the  calibre  of  the  aorta  in  many  cases. 
Sometimes  it  was  even  reduced  to  a  mere  slit. 

'  N.  Y.  Medical  Journal,  June  2d,  i88S,  p.  599. 

=■  Neidert,  Inaug.   Diss.  (Munich,  1886).         3  Rev.  de  Chin,  Aug.  loth,  1SS6,  p.  671. 


ORTHOPEDIC  SURGERY. 


Phthisis  is  of  course  common  from  diminished  chest  capacity  as 
well  as  from  the  ever-present  inability  of  the  dissemination  of 
tuberculosis  from  the  bone  focus. 


Fig. 


Fig.  12. — Complete  Absorption  of  Vertebral  Body.  (Warren  Museum.) 


Fig.  14. — Complete  Bony  Anky- 
losis.    (Warren  Museum.) 


Fig.  15. — Section  of  Such  a 
Union  of  Vertebrae. 


Fig.  II. — Compression  of  the  Spinal  Cord  and  Pressure  Myelitis.  D,  Mid-dorsal  region  near  the  point  of 
compression;  C,  one  and  one-half  inches  higher  up,  showing  a  slighter  degree  of  myelitis;  B,  first  dorsal, 
slighter  myelitis,  ascending  degeneration;  E,  one  and  one-half  inches  below  pressure  point,  general  my- 
elitis;  F,  two  inches  lower  down,  descending  degeneration  of  pyramidal  tracts  and  "  comma- shaped '' 
descending  degeneration  in  anterior  part  of  posterior  external  column;  G,  lowest  part  of  dorsal  region^  only" 
descending  degeneration  of  pyramidal  tracts. 


POTTS   DISEASE,  c, 

A  cure,  however,  is  possible  even  in  cases  with  very  advanced 
deformity.  This  cure  can  come  about  in  one  cjr  two  ways:  (i)  by 
ankylosis  between  the  surfaces  of  the  bodies  of  the  diseased  ver- 
tebrae— a  very  slow  process,  whicli  requires  years  for  its  comple- 
tion ;  (2)  by  the  ossification  of  the  inflammatory  material,  thrown 
out  around  the  column  and  by  the  action  of  the  formative  ostitis 
which  accompanies  the  destructive  process,  the  vertebral  column  is 
supported,  as  it  were,  in  surrounding  bone.  This  ossification  is 
more  marked  around  the  articular  and  transverse  processes  than  at 
the  seat  of  the  disease.' 


Occurrence  and  Etiology. 

Sex. — Sex  does  not  appear  to  be  an  important  factor  in  causing 
Pott's  disease,  though  statistics  vary  somewhat.  Gibney  found  in 
2,455  cases,  1,329  males  and  1,126  females.  Mohr  found  females 
slightly  more  numerous  than  males.     Fisher,  in   500  cases,  found 


Fig.  16. — Healed  Kyphosis  in  Dorsal  Region. 


261  males  and  239  females.  Taylor  in  412  cases  found  234  boys 
and  177  girls.  Of  294  cases  treated  at  the  Children's  Hospital  in 
the  last  four  years  there  were  152  boys  and  142  girls. 

Age. — The  disease  is  more  common  in  childhood.  Mohr  found, 
in  72  cases,  that  the  disease  occurred  between  the  first  and  fifth 
years  in  29  per  cent ;  between  the  sixth  and  tenth  years  in  22  per 
cent;  between  the  eleventh  and  fifteenth  years,  22  per  cent ;    be- 

'  Alexander,  Liv.  Med.  Chir.  Journ.,  July,  1SS7,  p.  367. 


lO  ORTHOPEDIC  SURGERY. 

tvveen  the  sixteenth  and  twentieth  years,  i6  per  cent;  and  above 
the  twentieth  year  in  ii  per  cent.  Drachman  found,  in  i6i  cases, 
41  per  cent  between  one  and  five  years;  36  per  cent  between  five 
and  ten  years;  13  per  cent  between  ten  and  fifteen  years;  5  per 
cent  between  fifteen  and  twenty  years;  4  per  cent  between  twenty 
and  twenty-five  years.  The  oldest  case  was  seventy-seven  years  of 
age,  and  the  youngest  eight  weeks.  Gibney  found  that  87  per  cent 
were  under  fourteen  years  of  age;  7  percent  between  fourteen 
and  twelve ;  and  4  per  cent  over  twenty-one.  Taylor  found,  in  375 
cases,  that  226  were  under  five;  68  between  five  and  ten;  and  24 
between  ten  and  fifteen  (N.  Y.  Med.  Record,  August  13th,  1881). 

Freqziency  of  Occurrence. — Jaffe  found,  in  the  post-mortem  exam- 
ination of  317  cases  of  tuberculosis  of  bones  and  joints,  that  there 
was  caries  of  the  spine  in  26  per  cent  of  the  cases;  in  bones  of  the 
feet  in  21  per  cent;  in  the  hip-joint  in  13  per  cent;  in  the  knee- 
joint,  in  10  per  cent;  in  the  hand,  in  9  per  cent;  and  in  the  elbow, 
in  4  per  cent. 

The  erect  position  of  the  body  is  a  factor  of  importance  in  caus- 
ing disease  of  the  spine,  or,  in  other  words,  that  position  which 
necessitates  superincumbent  pressure  upon  an  injured  vertebral 
body.     Caries  of  the  spine  is  said  not  to  be  found  in  quadrupeds. 

Localization. — The  mobility  of  the  spine — that  is,  the  forward 
bending  of  the  spine — appears  to  influence  to  some  extent  the 
localization  of  the  disease,  although  this  is  a  matter  not  fully  de- 
termined. Any  of  th2  vertebrae  may  be  attacked,  but  in  varying 
frequency.  Statistics  are  of  uncertain  value,  as  they  are  chiefly 
based  upon  autopsies  and,  therefore,  from  adults.  Mohr,  in  fifty-six 
autopsies  of  caries  of  the  spine,  found  that  the  disease  is  most  com- 
mon in  the  thoracic  region  (thirty-three  in  fifty-six  cases),  next  in 
the  lumbar  region  (twenty-seven  times),  and  next  in  the  neck 
(twelve  times).  The  sacrum  was  diseased  in  one  case.  As  there 
are  more  dorsal  vertebrae  than  either  cervical  or  lumbar,  it  is  natu- 
ral that  the  number  of  cases  of  dorsal  disease  should  be  greater 
than  in  the  other  regions.  In  adults  Mohr  found  the  first  lumbar 
to  be  the  one  most  frequently  diseased,  the  second  lumbar  the 
next;  the  fourth  dorsal,  the  twelfth  dorsal,  and  the  fifth  lumbar 
were  attacked  nearly  as  frequently.  Billroth  and  Menzel  found,  in 
autopsies,  the  first  and  second  cervical  vertebrae  the  ones  most  fre- 
quently attacked,  and  next  to  these  the  sixth,  the  fourth,  and  the 
eighth  dorsal,  the  fourth  and  the  fifth  lumbar,  the  tenth  and  the 
ninth  dorsal,  and  the  third  cervical,  in  the  above  order.  The  ver- 
tebrae least  frequently  attacked  were,  according  to  Mohr,  the  ninth, 
the  tenth,  and  the  eleventh  dorsal,  the  fourth  lumbar,  and  the  fifth 
and  the  sixth  cervical.     Billroth  and  Menzel  found  the  fifth  and 


POTTS  DISfiASK.  U 

the  sixth  cervical,  the  first  and  the  second  dorsal,  tlic  first  lumbar, 
the  vertebra  least  often  attacked.  Jaffe  found,  in  the  exam- 
ination of  living  subjects,  that  the  sixth  and  the  seventh  dorsal 
were  the  vertebrae  most  freciuently  attacked ;  and  he  found,  also, 
that  the  lumbar  vertebra;  were  less  frequently,  and  the  cervical 
more  frequently,  the  seat  of  disease  than  had  been  supposed  from 
post-mortem  examination. 

Taylor  found,  in  an  examination  of  300  living  patients  with  caries 
of  the  spine,  that  the  points  of  greatest  liability  to  the  disease  arc 
first,  the  sixth  and  the  seventh  cervical ;  second,  near  the  eightli 
dorsal;  third,  the  second  and  the  third  lumbar.  The  points  of 
least  liability  to  the  disease  are  from  the  first  to  the  fourth  dorsal 
an'd  the  eleventh  and  the  twelfth  dorsal,  besides  the  two  extremi- 
ties of  the  spinal  column.  Although,  as  is  seen,  the  locations  of 
relative  frequency  given  by  the  different  observers  do  not  agree,  it 
would  appear  that  certain  portions  of  the  spine  are  more  liable  to 
attack  than  certain  others,  and  that  the  theory  advanced  by  Taylor 
was  a  plausible  one — viz.,  that  the  regions  most  liable  to  the  dis- 
ease were  those  which  were  the  most  exposed  to  jars  or  increased 
pressure;  and  that  the  disease  would  be  more  frequent  where  the 
hinges  of  motion  at  the  spinal  column  came,  varying  to  a  degree 
according  to  age  and  occupation,  or  where  there  was  the  greatest 
exposure  to  the  effects  of  violent  jars. 

In  short,  it  may  be  assumed  that  the  determining  cause  of  caries 
of  spine  is  jar  or  superincumbent  pressure;  the  influential  cause 
that  physical  state  which  is  incapable  of  resisting  slight  trauma, 
exposing  the  tissue  probably  to  the  invasion  of  the  tubercle 
bacillus. 

How  Pott's  disease  is  caused  is  not  yet  definitely  determined. 
That  the  disease  is  of  a  tuberculous  nature  is  frequently  asserted 
and  seems  probable,  and,  as  is  often  the  case,  some  fall  or  injury 
can  be  regarded  as  an  exciting  cause. 

Gibney,  in  an  examination  of  185  cases,  found  a  hereditary 
tuberculous  taint  in  'j^  per  cent.  In  35  per  cent  this  was  inherited 
from  the  father;  in  38  per  cent  from  the  mother;  in  31  per  cent 
from  both.  In  15  per  cent  it  existed  in  other  children  of  the 
family,  and  in  16  per  cent  the  taint  was  manifest  in  both  parents 
and  children.  In  45  per  cent  a  weakened  condition  from  previous 
sickness  was  found;  and  in  22  per  cent  both  an  inherited  and  an 
acquired  diathesis  were  found.  Taylor,  in  845  cases,  found  53  per 
cent  with  a  history  of  preceding  trauma;  in  15  per  cent  there  was 
disease  of  the  lung  in  nearer  or  more  distant  relatives;  in  19  per 
cent  so-called  scrofula  was  asserted,  and  in  34  per  cent  a  sickly 
diathesis. 


12  ORTHOPEDIC  SURGERY. 

In  general  it  is  more  common  than  not  to  find  phthisis  present 
in  the  family  history,  near  or  remote,  or  some  decided  cause  for 
the  affection  in  the  child's  own  history,  such  as  measles,  scarlet 
fever,  or  some  wasting  illness,  and  whooping  cough  is  said  by  some 
writers  to  be  an  etiological  factor  of  importance  in  Pott's  disease. 
In  certain  instances  this  would  seem,  from  the  history  of  the  cases, 
to  be  probable.  The  etiology  of  tuberculous  affections  of  bone  is 
considered  at  length  in  Chapter  V. 

Symptoms. 

Few  affections  have  a  clinical  history  which  varies  so  widely 
and  appears  under  such  different  guises  as  that  of  Pott's  disease. 
In  the  cervical  region  the  disease  may  appear  to  be  an  idio- 
pathic torticollis,  while  in  the  lumbar  region  it  often  simulates 
hip  disease  so  closely  as  to  render  an  immediate  diagnosis  impossi- 
ble. The  one  constant  symptom,  however,  which  accompanies  all 
cases  of  Pott's  disease  and  must  often  form  the  chief  reliance  in 
diagnosis  is  muscular  rigidity  at  the  affected  portion  of  the  spine. 
Just  as  joint  fixation  is  the  constant  symptom  of  chronic  joint  dis- 
ease, so  is  restricted  motion  between  the  diseased  vertebrse  the  con- 
stant accompaniment  of  Pott's  disease,  in  its  early  stages  or  later. 

Typical  cases  of  Pott's  disease  are  so  characteristic  in  their 
symptoms  that  the  diagnosis  is  evident  alm.ost  at  a  glance.  The 
guarded  character  of  all  the  movements  is  perhaps  the  most  strik- 
ing feature.  In  Avalking,  in  stooping,  or  in  lying  down,  the  spine  is 
most  carefully  guarded  against  jar  and  against  motion,  attitudes 
are  assumed  which  relieve  the  vertebral  column  of  some  of  the 
weight  of  the  body,  and  a  glance  at  the  naked  child  shows  unnatural 
modes  of  standing  and  walking. 

A  prominence  of  the  vertebrse  is  ordinarily  present  as  early  as 
at  this  stage,  and  oftener  than  not  pain  is  acute  and  aggravated  by 
motion.  Constitutional  disturbance  is  also  very  likely  to  be  pres- 
ent when  the  disease  has  been  of  even  a  few  months'  duration. 

Peculiarity  of  attitude,  muscular  stiffness,  and  referred  pain  are 
the  most  prominent  of  the  earlier  symptoms,  and  they  may  be 
present  before  a  projection  has  been  noticed.  The  importance  of 
these  early  symptoms  can  hardly  be  overstated,  as  it  is  on  an  early 
recognition  of  the  affection  that  the  hope  of  a  ready  cure  is  to  be 
based. 

Attitude. — The  peculiarity  in  attitude  noticed  early  in  the  disease 
is  due  either  to  reflex  muscular  spasm — similar  to  that  seen  in 
joint-disease  (notably  that  of  the  hip-joint), — or  to  an  unconscious 
effort  on  the  part  of  the  patient  to  prevent  jar  or  any  increased 


J'OTT'S   JJ/SKASK. 


13: 


pressure  upon  the  affected  vertebral   bodies.     These  attitudes  nec- 
essarily vary  according  to  the  point  of  the  spine  attacked.      In  dis- 


FiG.  17. — Posterior  View  of  the  Position  in  Cer-  Fig.  18. — Attitude  in  Cer-  Fig.  19. — Attitude  in 

vical   Caries,  Showing   the   Tilting  of  the  Head      vical  Caries  of  only  Moder-        Severe     High     Dorsal 
which  so  often  Simulates  Torticollis.  ate  Seventy.  Caries. 


ease  of  the  upper  cervical  region,  the  most  common  attitude  is  that 
of  wry-neck.     This  is  sometimes  confounded  with  idiopathic  torti= 


,ij^ST5«t 


Fig.  20. — Position  of  Head  in  Cervical  Caries.  Fig.  21.— Frequent  Position  of  Head  in  Cervical  Caries. 


14 


ORTHOPEDIC  SURGERY. 


collis,  and  patients  in  some  instances  have  been  subjected  to  teno- 
tomy under  a  mistaken  diagnosis. 

When  the  disease  is  in  the  lower  cervical  or  upper  dorsal  region, 
the  chin  is  held  som.ewhat  raised,  to  balance  the  weight  of  the 
head  on  the  articular  facets,  suggesting  the  position  of  a  seal's 
head  when  out  of  water.  The  spinal  column  below  the  point  of 
disease  is  abnormally  straight,  and 
in  some  instances  curved  slightly 
forward^ while  in  the  lower  dorsal 
region  an  exaggerated  backward 
projection  of  the  spinous  proces- 
ses may  be  seen  ;  this  projection, 
due  to  a  compensating  curve,  is 
sometimes  so  marked  as  to  sug- 
gest that  the  disease  has  attacked  /  .  \  \ 
another  part  of  the  spine.                       /       K           /     \ 


Fig.  22. — Attitude  of  Head  and  Elevation  of 
Chin  in  Cervical  Caries. 


Fig.  23. — Elevated  Shoulders  in  Upper 
Dorsal  Disease. 


In  the  middle  dorsal  region,  the  attitude  to  be  noticed  most  fre- 
quently is  an  elevation  of  the  shoulders.  Sometimes  one  shoulder 
is  held  for  a  time  higher  than  the  other,  and  temporarily  a  slight 
lateral  deviation  of  the  spine  is  to  be  seen.  In  the  lumbar  region, 
the  patient  in  the  early  stage  frequently  will  be  noticed  to  lean 


POTT'S  ])  IS  EASE. 


'5 


backward,  like  pregnant  women  or  adults  with  large  abdomens.  A 
peculiar  position  and  characteristic  sidling  gait,  which  is  sometimes 
seen  at  a  comparatively  early  stage  of  disease  in  the  lower  dorsal 
or  lumbar  region,  is  due  to  a  slight  contraction  of  the  psoas  and 
iliacus  muscles. 

In  a  late  stage,  when  psoas  abscess  is  present,  a  marked  contrac- 
tion of  these  muscles  takes  place ;    but  even  when  there  is  no  evi- 


FiG.  24. — Lordosis  in  Lumbar  Pott's  Disease. 


Fig.  25. — Attitude  in  Pronounced  Dorsal  Caries. 


dence  of  existence  of  suppuration  or  of  a  psoas  abscess,  slight  in- 
flammatory irritation  of  the  muscles  will  produce  a  limitation  to 
the  arc  of  extension  of  the  thigh  on  the  trunk.  This  may  be  so 
slight  as  to  be  noticed  only  by  placing  the  patient  on  the  face  and 
attempting  extreme  extension  of  the  thigh.  If  more  muscular  re- 
sistance is  met  on  one  side  than  on  the  other,  or  than  is  usually 
encountered,  it  may  be  assumed  that  the  increased  tonicity  is  the 
result  of  irritation  of  some  of  the  muscular  fibres  extending  the 
this;!!. 


l6  ORTHOPEDIC  SURGERY. 

In  addition  to  the  square  position  of  the  shoulders,  the  pecuHar 
position  of  the  head,  and  the  erect  attitude  of  the  upper  part  of 
the  spine,  which  prevents  the  superincumbent  weight  of  the  trunk 
and  upper  extremities  (above  the  diseased  portion  of  the  spine) 
from  faUing  forward  upon  the  diseased  vertebral  body,  the  gait  is 
peculiar;  the  patient  walks  more  on  the  toes  than  on  the  heels,  and 
with  the  knees  slightly  bent — in  such  a  way  that  all  possibles 
springs  may  be  brought  into  play  to  diminish  jarring  the  spine. 

These  peculiarities  of  attitude  and  position  vary  in  severity  ac- 
cording to  the  severity  of  the  disease ;  they  may  be  at  one  time 
more  noticeable  than  at  another.  Characteristic  also  at  this  stage 
of  the  disease  is  a  muscular  stiffness,  which  becomes  more  marked 
after  the  patient  has  been  quiet  for  a  while  (during  sleep).  The 
stiffness  of  the  limbs  diminishes  or  disappears  after  the  patient  has 
moved  about.  A  certain  amount  of  muscular  rigidity  of  the  mus- 
cles of  the  back  will  be  felt  on  palpation  in  affections  of  the  middle 
dorsal  and  lumbar  regions;  stooping  which  involves  arching  of  the 
back  forward  is  difficult  or  impossible,  and  in  attempting  to  stoop 
in  order  to  pick  up  any  article  from  the  floor  the  patient  will  keep 
the  spine  erect  and  reach  the  floor,  lowering  himself  with  an  erect 
trunk,  by  bending  the  knees  (Fig.  27), 

It  will  often  be  noticed  that  children  become  tired  more  easily 
than  usual,  and  after  playing  about  for  a  time  will  desire  to  lie 
down,  to  rest  their  arms  upon  a  chair  or  seat,  or  to  support  the 
head  with  their  hands,  or  the  trunk  by  holding  on  to  the  thighs, 
according  to  the  part  of  the  spine  affected  (Figs.  26  and  28). 

The  amount  of  muscular  stiffness,  rigidity,  and  difificulty  in  main 
taining  the  spine  erect  is  in  a  measure  an  index  of  the  degree  of 
activity  of  the  disease.  In  early  cases  the  muscles  on  either  side 
of  the  area  of  the  affected  vertebrae  will  often,  on  bending  the 
back,  be  seen  to  spring  out  in  relief,  acting  like  physiological 
splints  to  the  diseased  vertebral  column. 

Attitude  in  Psoas  Contraction. — Various  modifications  of  charac- 
teristic attitudes  are  at  times  produced.  The  most  common  of 
these  probably  is  the  flexion  of  the  thigh  which  results  from  psoas 
contraction,  usually  the  result  of  psoas  abscess.  The  contraction 
of  the  muscle  is  both  the  warning  and  the  accompaniment  of  the 
abscess.  The  results  may  be  seen  in  Figs.  31  and  32.  In  the  first 
only  in  a  slight  degree;  in  the  second  case  to  such  a  degree  that 
the 'leg  cannot  be  put  to  the  ground  in  walking  and  the  use  of  a 
crutch  is  necessitated. 

An  attitude  necessitated  in  the  more  acute  cases  of  psoas  abscess 
is  seen  in  Fig.  29,  where  a  large  psoas  abscess  was  present. 

The  detection  of  mild  degrees  of  psoas  contraction  is  accom- 


POTT'S   DISI'lASE 


17 


Fig.  26. — An  Occasional  Attitude  Assumed  in 
Acute  Pott's  Disease,  Especially  when  the  Dis- 
ease is  in  the  Cervical  Region. 


Fig.  27.— Characteristic  Attitude  in 
Stooping. 


Fig.  28.— Attitude  Assumed  by  Children  with 
Acute  Pott's  Disease,  and  in  Other  Cases  Ne- 
cessitated by  Psoas  Contraction. 


Fig.  29.— Attitude  in  Severe  Pott's  Disease  with 
Psoas  Contraction  and  Abscess. 


ORTHOPEDIC  SURGERY. 


plished  by  the  simple  manipulation  shown  in  the  figure,  by  which 
one  at  once  appreciates  the  loss  of  the  hyperextension  of  the 
thigh. . 

Lateral   dirvatttre  of  the   Spine   in  Potfs  Disease. — Lateral  de- 
viation   of   the    spine    is    ah    occasional  attitude    to    be   found    in 

Pott's  disease  and  is  discussed  at  length 
in  its  relation  to  lateral  curvature  under 
the  head  of  diagnosis.  As  a  rule  the 
lateral  curvature  of  Pott's  disease  is  char- 
acterized by  very  slight,  if  any,  rotation 
of  the  spinal  column  on  a  vertical  axis. 
Dr.  Bartow,'  in  a  recent  very  interesting 
article  on  the  subject,  however,  advocates 
the  view  that  rotation  is  much  more  com- 
mon than  has  been  supposed.  He  says: 
"  Pathological  spinal  rotation  is  always 
associated  with  the  early  stage  of  spondy- 
litis in  the  regions  that  I  have  mentioned 
(dorso-lumbar)."  The  experience  of  the 
writers  would  lead  them  to  believe  that 
generally  rotation  of  the  spinal  column 
was  imperceptible  in  these  cases. 

Dr.  Bartow's  article  is  illustrat'ed  to 
show  most  admirably  the  characteristic 
attitude  apart  from  any  question  of  rota- 
tion. The  lateral  deviation  has  no  espe- 
cial significance  except  in  indicating  a 
certain  modification  of  treatment  to  be 
considered  later.  It  is  sometimes  the  first 
symptom  of  Pott's  disease  and  one  which 
has  attracted  but  little  attention. 

Pain. — In  certain  cases  of  Pott's  disease 
pain  is  absent  altogether,  but  it  is  often 
present  to  a  most  distressing  degree,  and 
it  forms  a  more  prominent  symptom  than 
it  does  in  hip  disease  or  tumor  albus,  for 
instance.  In  a  measure  it  tends  to  mislead 
both  parents  and  physician,  for  the  pain 
is  rarely  complained  of  in  the  back,  but  referred  to  the  peripheral 
ends  of  the  nerves,  and  thus  described  as  being  felt  in  the  abdo- 
men, chest,  or  limbs.  Abdominal  pain  passes  for  "stomach  ache," 
and  pains  in  the  limbs    for  "  growing  pain."     In  general,  it  may 


':uJ 


Fig.  30. — Lateral  Deviation  of  the 
Spinal  Column  in  Lower  Dorsal 
Disease. 


Annals  of  Surgery,  July,  il 


POTTS   J)JSJCASK. 


19 


be  said  here  that  persistent  k^calized  pain  in  the  case  of  a  child  is  a 
symptom  demandint;  very  threat  attention. 

The  sleep  of  these  children  is  apt  to  be  much  disturbed  by  pain, 


Fig.  31. — Mild  Degree  of  Psoas  Contraction, 
the  Result  of  Abscess. 


Fig.  32. — Severe  Grade  of  Psoas 
Contraction. 


Fig.  33. — Method  of  Examination  for  Psoas  Contraction  in  Pott's  Diseise. 


20  ORTHOPEDIC  SURGERY. 

for  the  suffering  from  Pott's  disease,  like  all  the  pain  of  bone  dis- 
eases, is  more  severe  at  night.  In  the  milder  cases  this  is  manifested 
by  simple  restlessness,  while  in  more  severe  cases  it  takes  the  form 
of  crying  spells.  This  may  even  be  the  case  where  the  children 
can  walk  about  without  pain  during  the  day.  "  Night  cries  "  are 
occasionally  present  in  Pott's  disease,  although  very  rarely,  if  one 
compares  their  infrequent  occurrence  here  with  their  prevalence 
in  hip  disease.  When  they  are  present,  however,  they  are  distinc- 
tive. The  child  falls  asleep  only  to  wake  with  a  sharp  scream  and 
perhaps  to  fall  asleep  again  by  the  time  that  the  parent  reaches 
the  bedside.  This  may  be  repeated  several  times  each  evening,  and 
as  a  rule  it  does  not  occur  by  any  means  so  commonly  later  in  the 
night.  The  early  evening  is  par  excellence  the  time  when  "  night 
cries  "  are  heard  in  any  form  of  joint  disease. 

The  pain  is  usually  subacute,  and  may  be  only  occasional.  At 
times  the  attack  may  be  very  severe,  accompanied  by  intense  hy- 
perassthesia,  so  that  the  pressure  of  the  bedclothes  cannot  be  toler- 
ated, and  patients  in  this  condition  have  been  supposed  to  have 
intense  peritonitis  or  pleurisy.  The  subacute  form  is  more  com- 
mon, and  this,  together  with  muscular  stiffness,  often  gives  rise  to 
a  diagnosis  of  rheumatism,  sciatica,  or  neuralgia.  The  pain  in 
these  cases  is  due  to  a  compression  of  the  nerves  by  inflammatory 
products  as  they  pass  out  of  the  spinal  canal.  Analogous  to  these 
attacks  of  pain  are  disturbances  of  the  functions  of  other  nerves 
— manifested  in  cough,  a  peculiar  grunting  respiration,  dyspnoea 
with  cyanosis,  gastric  disorders,  obstinate  and  recurring  vomiting, 
and  troubles  of  the  bladder,  with  or  without  pain  at  the  end  of  the 
penis.  Patients  suffering  in  this  way  have  been  treated  for  bron- 
chitis, pneumonia,  gastritis,  or  cystitis.  In  one  notable  instance 
the  operation  for  stone  in  the  bladder — lateral  cystotomy — was 
performed.  No  vesical  trouble  was  discovered,  but  at  the  autopsy 
caries  of  the  lumbar  vertebrae  was  found. 

These  periods  of  suffering  may  become  intense — constituting 
acute  attacks,  subsiding  after  rest,  and  recurring  at  intervals  with- 
out apparent  exciting  cause. 

Dilatation  or  contraction  of  the  pupil,  existing  for  some  time, 
has  been  noted  in  cervical  caries  of  the  spine,  with  compression  of 
the  cord  (Charcot). 

It  is  to  be  expected  that  pain  will  be  diminished  and  generally 
controlled  by  efificient  mechanical  treatment.  Certain  cases,  how- 
ever, are  from  the  first  so  intractable  that  pain  persists  in  spite  of 
all  that  can  be  done.  Fortunately  such  cases  are  not  the  rule,  and 
in  general  it  may  be  assumed  when  pain  comes  on  in  the  course  of 
treatment,  that  the  apparatus  does  not  fit,  if  mechanical  treatment 


POTT'S  JUS  EASE.  21 

is  used,  or  that  the  parents  are  not  careful  in  the  nursing  of  the 
child  or  in  carrying  out  treatment  thoroughly.  In  a  few  instances 
it  will  be  found  that  pain  can  for  a  time  not  be  entirely  checked  by 
treatment.  A  sudden  and  violent  increase  of  pain  should  lead  one 
to  suspect  an  approaching  access  of  the  disease — with  increase  of 
the  deformity — the  formation  of  an  abscess,  or  the  beginning  of 
paralysis. 

Paralysis. — Considering  the  fact  that  the  spinal  canal,  containing 
the  spinal  cord,  is  so  near  the  scat  of  disease  in  caries  of  the  spine, 
it  is  not  strange  that  paralysis  is  so  common  a  symptom  in 
Pott's  disease.  This  complication  is  more  frequent  the  higher  the 
portion  of  the  spinal  column  which  is  affected,  for  the  reason  that 
the  cord  is  larger  and  the  vertebral  bodies  smaller  the  higher  we 
ascend  in  the  column. 

But  as  a  rule  it  is  not  the  result  of  a  direct  compression  of  the 
cord  by  the  bony  arches  of  the  spinal  canal,  but  it  is  caused  by  a 
compression  myelitis  and  meningitis  set  up  by  the  contiguous  in- 
flammation. The  paralysis  does  not  always  occur  in  the  severest 
or  the  sharpest  deformities,  nor  is  it  proportionate  to  the  degree 
of  angular  curvature.  Mr.  Pott,  in  his  original  treatise,  wrote : 
"  Since  I  had  been  particularly  attentive  to  the  disorder,  I  thought 
that  I  had  observed  that  neither  the  extent  nor  degree  of 
the  curve  had  in  general  produced  any  material  difference  in  the 
symptoms,  but  that  the  smallest  was,  when  perfectly  formed,  at- 
tended with  the  same  consequences  as  the  largest  and  that  the  use- 
less state  of  the  limbs  is  by  no  means  a  consequence  of  the  altered 
figure  of  the  spine,  or  of  the  disposition  of  the  bones  with  regard 
to  each  other,  but  merely  of  the  caries." 

The  paralysis,  as  we  have  seen,  is  due  to  a  thickened  condition  of 
the  cord  membranes  inducing  a  compression  of  the  cord  and  a 
certain  degree  of  consequent  transverse  myelitis.  The  mischief  is 
sharply  limited  as  a  rule  to  the  seat  of  disease,  unless  the  process 
has  reached  so  severe  a  degree  that  descending  secondary  degen- 
eration of  the  cord  is  present. 

The  clinical  picture  is  what  one  would  expect  from  a  considera- 
tion of  the  pathological  condition ;  a  paralysis  of  motion  mild  or 
severe,  followed,  if  the  case  gets  worse,  by  a  paralysis  of  sensation, 
which  is  said  by  Courjon  never  to  become  complete.  The  motor 
paralysis  varies  from  mere  muscular  weakness  to  complete  loss  of 
power.  It  begins  as  a  sense  of  fatigue,  a  dragging  of  the  feet ;  then 
there  is  inability  to  hold  one's  self  erect.  Unless  the  disease  is  in  the 
lumbar  region,  the  reflexes  are  exaggerated,  and  muscular  spasms 
often  start  from  the  least  irritation ;  they  frequently  appear  spon- 
taneously.    The  muscles  are    flaccid    and  the    legs  are  powerless. 


22  ORTHOPEDIC  SURGERY. 

With  the  secondary  degenerations  in  the  cord  rigidity  sets  in;  first 
the  legs  are  rigid  in  the  extended  position,  then  flexion  accompa- 
nies the  permanent  contracture.  The  bladder  and  rectum  are  par- 
alyzed toward  the  end  of  all  very  bad  cases,  and  whenever  the 
lumbar  enlargement  is  involved ;  in  milder  cases  they  escape.  It 
is  hard  to  explain  why  the  arms  are  paralyzed  in  certain  cases  of 
dorsal  caries,  for  an  ascending  secondary  degeneration  of  the  cord 
should  give  rise  to  no  symptoms,  and  we  have  to  assume  an  ex- 
tended myelitis  or  meningitis.  Of  the  sensory  paralysis  below  the 
lesion  there  is  less  to  be  said;  it  is  apt  to  begin  as  paraesthesia ; 
anaesthesia  afterward  comes  on  to  a  greater  or  less  extent,  and 
when  this  occurs  it  means  a  pretty  extensive  transverse  myelitis. 
Trophic  disturbances  and  loss  of  electrical  contractility  are  not  to 
be  seen  unless  in  exceptional  cases,  where  other  parts  of  the  cord 
than  those  usually  affected  have  become  secondarily  changed. 

The  wasting  of  the  muscles  and  diminution  of  electric  contractil- 
ity are  usually  only  such  as  disuse  would  cause;  if,  however,  the 
lumbar  or  cervical  enlargement  is  attacked,  emaciation  of  the  mus- 
cles and  the  loss  of  faradic  contractility,  with  the  reaction  of  de- 
generation, are  to  be  noted. 

In  a  few  instances  affections  of  the  joints,  supposed  to  be  sec- 
ondary to  lesions  of  the  cord,  have  been  noted,  and  instances  are 
mentioned  in  which  herpes  zoster,  apparently  due  to  the  same 
cause,  was  present. 

Many  patients  with  Pott's  disease,  especially  children,  are  bed- 
ridden, or  at  least  non-ambulatory,  without  being  paralyzed. 
When  the  disease  runs  its  course  unchecked,  asthenia  is  often  pro- 
found, and  although  there  may  be  no  trace  of  paralysis,  the  patient 
frequently  has  no  desire  or  strength  to  walk  or  even  to  sit  up. 
Another  cause  which  sometimes  keeps  patients  off  their  feet,  inde- 
pendently of  paralysis,  is  psoas  contraction  of  a  severe  grade,  espe- 
cially if  it  be  bilateral.  Still  another  reason  is  a  preponderating 
mental  impression  of  inability  to  walk  or  stand.  Many  cases  per- 
sist in  walking  when  paralyzed  to  a  degree  which  ought  to  preclude 
it,  and  which  would  ordinarily  do  so,  while  others  are  bedridden 
with  little  or  no  paralysis,  or  remain  so  after  the  paralysis  has 
totally  disappeared,  having  recovered  without  being  conscious  of 
restoration.  This  accounts  for  the  suddenness  of  invasion,  and 
particularly  of  recovery,  in  some  of  these  paralyzed  cases. 

So  great  is  the  general  weakness  induced  by  Pott's  disease  in 
severe  cases  that  an  inability  to  walk  results  from  weakness  alone 
without  any  affection  of  the  cord.  The  limbs  are  generally  wasted, 
but  the  reflexes  are  normal,  and  on  this  one  must  depend  to  differ- 
entiate the  affection  from  compression  myelitis. 


POTTS  DISEASE. 


23 


Paralysis  is  rarely  an  early  symptom  in  caries  of  the  spine, 
though  it  has  been  observed  before  the  stage  of  deformity;  it  is 
sometimes  partial;  it  is  usually  preceded  by  paresis;  it  may  in  rare 
instances  precede  deformity.  The  frequency  of  paralysis  is  indi- 
cated by  the  figures  collected  by  Gibney.  Out  of  295  patients  with 
caries  of  the  spine,  paralysis  was  noted  62  times;  in  189  cases  of 
caries  of  the  upper  dorsal  and  cervical  region,  paralysis  occurred 
in  59 ;  in  106  cases  of  lower  dorsal  and  lumbar  disease,  paralysis 
occurred  in  only  three. 

Paralysis  is  usually  bilateral;  it  may,  however,  be  unilateral,  and 
in  some  unusual  instances  it  occurs  above  the  point  of  deformity. 
Taylor  and  Lovett  found  in  an  examination  of  59  cases  (out  of  445 
cases  of  Pott's  disease)  that  the  location  of  disease  was  as  follows: 
I  cervical,  7  cervico-dorsal,  37  dorsal,  7  dorso-lumbar,  4  lumbar,  3 
unclassified.  The  deformity  was  large  in  20,  medium  in  10,  small 
in  17  (in  12  unclassified).  The  paralyzed  cases  presented  no  worse 
deformity  than  that  seen  in  average  cases.  In  26  the  outline  of 
the  deformity  was  rounded  and  gradual;  in  16  it  was  distinctly 
sharp.  The  paralysis  occurred  on  the  average  about  two  years 
after  the  beginning  of  the  disease.  It  came  on  immediately  after  a 
fall  in  4  cases,  in  8  cases  it  appeared  within  one  year,  in  26  within 
four  years,  in  i  within  five,  in  29  within  eleven,  and  in  10  within 
twenty-eight  years.  The  duration  of  the  paralysis  was  never,  in 
the  cases  reported,  over  three  years,  except  in  i  case,  where  it 
persisted  with  but  little  improvement  for  six  years ;  in  2  cases  it 
lasted  three  years;  in  5  cases  it  lasted  two  years.  A  recurrence  of 
the  paralysis  was  noted  in  6  cases,  4  having  two  attacks  and  2 
having  three. 

Out  of  72  cases  of  caries  of  the  spine  watched  by  Mohr,  there 
was  paralysis  in  seven  per  cent;  and  of  61  cases  of  autopsy  in 
deaths  from  caries  of  the  spine,  alteration  and  disease  of  the  cord 
was  found  in  eleven  per  cent. 

Paralysis  is  an  affection  of  rare  occurrence  in  Pott's  disease 
under  efficient  protective  treatment.  It  occurs  without  regard  to 
the  amount  or  character  of  the  deformity,  and  is  often  preceded 
by  much  pain ;  on  the  average  it  lasts  a  little  less  than  a  year.  Its 
prognosis  is  extremely  favorable  in  mild  cases,  or  in  severe  ones  if 
they  can  be  treated  early.  Recovery,  when  it  occurs,  is  generally 
complete,  no  trace  of  the  disability  of  the  limbs  being  left.  In- 
complete recovery  is  uncommon,  but  incomplete  paralysis  often  is 
present.  In  fact  the  early  commencement  of  efficient  treatment 
will  often  seem  to  render  abortive  an  attack  of  paraplegia,  and 
change  what  threatened  to  be  a  complete  loss  of  power  to  a  com- 
paratively trifling  disability  which  is  merely  enough  to  prevent 
walkinsf  for  a  few  weeks  or  months. 


Fig.  34, — Rounded  Outline  of  Deformity  as  seen 
in  Cured  or  Convalescent  Pott's  Disease. 


Fig.  35. — Sharp  Angle  of  the  Acute 
Stage. 


Fig.  36. — Slight  Projection  of  Dorsal  Region. 
Early  Caries  of  Spine. 


Fig,  37. — Projection  of  Dorsal  Region  in 
Caries  of  the  Spine.  More  advanced  than 
that  shown  in  Fig.  36. 


J'OTT'S  JUS  EASE. 


25 


Deformity. — The  most  characteristic  feature  of  Pott's  disease  is 
the  deformity — that  is,  the  projection  backward  of  one  or  more 
spinous  processes.  This  is  occasioned  by  the  destruction  of  the 
vertebral  bodies  which  form  the  anterior 
support  of  the  spine.  When  this  is  re- 
moved, the  spinal  column  above  the  dis- 
ease falls  forward,  throwing  the  spinous 
processes  out  of  the  vertical  line,  and  caus- 
ing a  projection  at  the  diseased  point. 

The  projection  is  primarily  of  the  affected 
vertebrae;  but  following  this  other  verte- 
brae are  more  or  less  involved,  and  the 
curve  increases,  with  the  establishment  of 
secondary  curves.  The  sharper  the  pro- 
jection, as  a  rule,  the    more    acute  is  the 

process;  but  this  rule,  however  absolutely        Fig.  38. -Extreme Kyphosis. 
true  in  the  upper  dorsal  region,  has  occasional  exceptions  in  the 
lower  dorsal  and  upper  lumbar  regions.     It  may  be  stated  that  in  - 
old  cases  there  is,  as  a  rule,  more  of  a  curve  and  less  of  an  angle. 


Fig.  39. — Method  of  Takiag  Tracings  of  the  Spine. 

It  is  not  absolutely  true  that  the  greater  the  amount  of  the  disease 
the  greater  the  deformity,  for  there  may  be  extensive  disease  on 
the  front  of  several  bodies  without  diminishing  the  weight-bearing 


26 


ORTHOPEDIC  SURGERY. 


function  ot  all  of  them;  but,  generally,  the  more  vertebrse  in- 
volved, the  greater  is  the  pro- 
jection. 

It  is  most  important  to  keep 
a  record  of  the  deformity  in 
each  case  under  observation. 
This  record  is  most  easily  taken 
by  the  simple  method  shown  in 

Fig.  39- 

A  strip  of  sheet  lead  half  an 
inch  wide,  of  the  quality  known 
to  the  dealers  as  "  four  pounds 
to  the  foot,"  is  made  straight 
by  pressing  out  the  curves,  and 
is  laid  along  the  spinous  pro- 


FiG.  40.— Tracing  Outlines  of  Spinal  Curves,  showing  Change  in 
the  Progress  of  Disease.   The  eailiest  tracings  are  on  the  right. 


Fig.  41. — Tracings  of  Different 
Varieties  of  Kyphosis. 


cesses  of  the  child,  who  lies  on  his 
face  with  his  hands  at  his  sides,  and 
his  head  turned  to  one  side.  With 
the  fingers  the  lead  is  pressed  against 
the  spinous  processes,  and  when  it  is 


Fig.  42. — Outline  of  Back  in  the  Adult  in  Exten- 
tensive  Lumbar  Pott's  Disease. 


Fig.  43.— High  Dorsal  Pott's  Disease  showing  also 
the  Deformity  of  the  Chest. 


POTT'S  DISEASE. 


27 


removed  it  is  stiff  enough  to  keep  its  shape.  The  curve  is  then 
drawn  upon  a  piece  of  cardboard  by  means  of  this  lead  strip,  placed 
on  its  side  and  used  as  a  ruler.  The  card-board  curve  is  cut  out 
with  scissors  and  the  concavity  is  then  applied  to  the  child's  back  to 
see  if  it  fits  accurately.  If  not,  it  should  be  trimmed  with  the  scissors 
until  it  does.  The  slightest  change  in  the  outline  of  the  back  can 
then  be  detected  at  any  subsequent  visit,  because  any  increase  or 
diminution  of  the  deformity  will  prevent  the  cardboard  cutting  from 
fitting  perfectly  the  outline  of  the  back. 

If  the  deformity  is  left  to  itself,  its  tendency  is  to  increase  until 
a  spontaneous  cure  results  or  death  ensues.  In  many  cases  in  dor- 
sal Pott's  disease  this  result  is  reached  only  after  an  enormous 
deformity  has  occurred.  In  cervical  and  lumbar  Pott's  disease 
spontaneous  cure  is  more  likely  to  occur,  and,  when  it  occurs,  is 
accompanied  by  much  less  deformity  than  in  the  dorsal  region. 

When  this  spontaneous  cure  occurs,  the  change  takes  place  grad- 
ually and  does  not  cause  narrowing  of  the  spinal  canal;  the  inter- 
articular  facets  become  united,  and  the  bodies  may  be  welded 
together  so  as  to  form  practically  one  bone;  in  cured  cases  the 
curvature  which  has  been  sharp  becomes  rounded  into  a  curve 
with  a  relatively  long  radius.  In  the  cervical  region,  however,  this 
rounding  is  not  as  marked  as  in  the  other  regions.  The  gibbosity 
is  most  marked  in  caries  of  the  upper  dorsal  region ;  the  curve  in 
the  lumbar  region  is  an  arc  with  a  longer  radius  than  is  found 
elsewhere  in  the  spine.  The  secondary  curvatures  are,  in  cervical 
caries,  a  dorsal  incurvation  below  the  disease,  with  a  slight  lumbar 
excurvation;  in  dorsal  disease  an  increased  hollowing  in  above  and 
below  the  gibbosity  of  the  disease ;  in  lumbar  caries  a  long  curva- 
ture with  convexity  inward  above  the  disease.  The  neck  becomes 
shortened  and  thickened  in  cervical  caries;  the  trunk  is  shortened 
in  disease  of  other  parts  of  the  spine;  there  may  be  also  a  diminu- 
tion of  an  uncertain  origin  in  the  growth  of  the  whole  body.  In 
severe  cases  the  limbs  more  usually  grow  to  the  normal  amount, 
and  are  necessarily  out  of  proportion  to  the  length  of  the  trunk. 
An  alteration  in  the  shape  of  the  lower  part  of  the  face  takes  place 
in  marked  dorsal  disease,  with  a  facial  expression  which  is  charac- 
teristic. 

A  spontaneous  arrest  of  the  disease  without  much  deformity 
may  take  place  in  cervical  caries,  although  instances  must  be  un- 
common;  the  same  is  true  of  lower  dorsal  and  lumbar  disease;  the 
curvature,  however,  is  necessarily  larger  and  the  cases  less  common 
than  in  cervical  caries. 

When  the  deformity  is  under  treatment,  it  is  to  be  hoped  that  it 
will  be  prevented  from  growing  much  larger.     In  the  mid-dorsal 


28 


ORTHOPEDIC  SURGERY. 


Fig.  44. — Showing  Shortening  of  Trunk  in  Pott's       Fig.  45. — Square  Shoulders  of  Pott's  Disease  and  Slight 
Disease  of  Moderate  Grade.  Lateral  Deviation  of  the  Column. 


Fig.  46. — Tracings  from  Cases  of  Pott's  Disease  showing  the  Recession  of  the  Deformity  under 
Mechanical  Treatment. 


POTTS  jjjsi-:ase. 


29 


region,  however,  it  is  generally  impossible  to  prevent  it  from  in- 
creasing slightly,  whatever  be  the  treatment;  and,  especially  if  the 
treatment  is  incomplete  on  the  part  of  either  parents  or  surgeon, 
the  deformity  in  this  region  is  likely  to  increase  considerably.  In 
certain  cases  the  disease  is  so  acute  and  the  process  of  destruction 
so  rapid  that  even  with  the  most  careful  treatment  increase  of  the 
deformity  is  not  to  be  prevented.  The  accompanying  figure  shows 
the  progress  of  the  disease  in  one  of  these  very  acute  cases  in  which 
the  care  at  home  has  been  perfect  and  the  brace  is  thoroughly 
ef^cient.  Recession  of  the  deformity  is  at  times  the  result  of 
careful  mechanical  treatment,  but  such  a  result  is  exceptional  and 
only  to  be  obtained  under  the  most  favorable  conditions.  Fig.  46, 
showing  the  tracings  in  some 
of  the  cases,  is  from  the  ad- 
mirable article  by  Dr.  Henry 
Ling  Taylor.' 

Cases  in  Avhich  the  deform- 
ity is  rapidly  increasing  are  as 
a  rule  characterized  by  much 
pain.  In  general  it  may  be 
assumed  that  a  sharp  and 
angular  deformity  indicates 
active  and  progressing  dis- 
ease. A  sudden  chafing  of 
the  skin  which  develops  un- 
der a  brace  which  has  always 
fitted  well,  should  lead  to  the 
suspicion  that  the  deformity 
may  be  increasing,  although 
that  may  not  be  necessarily 
the  case. 

Deformity  of  the  chest  is  a  constant  accompaniment  of  dorsal 
Pott's  disease.  The  vertebral  column  cannot  give  way  and  form 
an  angular  deformity  without  altering  the  position  of  the  sternum 
and  ribs.  The  deformity  is  usually  a  thrusting  downward  and  for- 
ward of  the  sternum  with  a  lateral  flattening  of  the  chest.  In 
short,  it  results  in  the  formation  of  a  pigeon-breast  so  closely  re- 
sembling that  caused  by  severe  rickets  as  to  be  often  mistaken  for 
it  at  times.  There  may,  however,  be  a  prominence  of  the  ribs  on 
both  sides  of  the  sternum,  as  is  shown  in  the  figure,  where  a  depres- 
sion of  the  sternum  is  seen.  Sometimes  the  pigeon-breast  is  the 
first  symptom  to  attract  the  attention  of  the  parents,  and  for  that 
alone  the  children  are  brought  to  the  surgeon. 

'  Med.  Rec,  Jan.  8th,  1SS7. 


Fig.  47. — Depression  of  the  Sternum  in  Dorsal  Pott's 
Disease. 


30 


ORTHOPEDIC  SURGERY. 


Abscess. — In  many  cases  of  Pott's  disease  the  whole  course  is  run 
without  any  evidence  of  suppuration,  but  in  others  abscesses  form 
a  distressing  comphcation. 

The  earHer  treatment  is  begun  and  the  more  efificiently  it  is  car- 
ried out,  the  less  liable  are  abscesses  to  form,  but  it  must  not  be 
assumed  that  the  occurrence  of  abscesses  is  evidence  of  incomplete 
treatment.     In  many  cases  an  abscess  cannot  be  avoided. 

The  causes  of  the  development  of  an  abscess  are  the  same  in 
Pott's  disease  as  in  caries  elsewhere.  What  the  abscess-determin- 
ing influences  are,  which,  in  some  instances,  give  rise  to  profuse 
suppuration,  and  the  absence  of  which,  in  other  cases,  allows  an 


Fig.  48. — Psoas  Abscess. 

immunity,  is  at  present  conjectural.  They  may  be  supposed  to  be 
dependent  on  the  amount  of  constitutional  or  local  power  of  resist- 
ance on  the  part  of  the  patient ;  the  extent  of  the  bacillary  invasion 
and  resulting  suppuration;  the  severity  of  a  previous  injury ;  and 
the  individual  degree  of  recuperative  power,  or  of  reparative  tissue- 
development.  If  we  consider  the  situation  of  the  vertebral  bodies 
(the  point  of  origin  of  abscesses) — projecting  into  the  cavities  of 
the  thorax  and  abdomen,  surrounded  by  the  lungs  and  intestines, 
close  to  the  large  vessels  and  the  oesophagus — it  will  seem  extraor- 
dinary that  the  formation  of  an  abscess  does  not  more  frequently 
lead  to  a  fatal  termination.  In  fact,  however,  the  fluid  contents  of 
the  abscesses  follow  in  the  line  of  least  resistance,  and  the  layers  of 


rorr's  disease.  31 

fascia;,  in  most  cases,  protect  tlic  larger  cavities  of  the  trunk  from 
invasion ;  the  pus  generally  extends  along  the  sheath  of  the  mus- 
cles and  comes  to  the  surface  at  points  distant  from  its  origin,  ap- 
pearing in  the  neck,  the  back,  the  axilla,  in  the  lumbar  region,  in 
the  groin,  or  in  Scarpa's  triangle.  These  purulent  collections  arc 
classified  respectively  as  lumbar,  iliac,  and  psoas  abscesses. 

Of  these  classes  psoas  abscess  is  the  most  common.  It  is  very 
rarely  met  with  in  children  unless  in  connection  with  vertebral  dis- 
ease, but  in  general  it  is  an  almost  pathognomonic  sign  of  dorsal 
or  lumbar  Pott's  disease.  Shaw  describes  its  formation  as  follows: 
*'  When  the  abscess  is  connected  with  diseased  dorsal  vertebrae,  it 
encounters  in  its  descent  the  diaphragm.  But  the  barrier  is  over- 
come by  a  particular  process.  As  the  abscess  comes  in  contact 
with  the  diaphragm  and  compresses  it,  adhesive  inflammation  is 
set  up  in  their  respective  surfaces.  The  consequence  is  that  they 
become  united  over  a  considerable  area;  an  opening  is  next  formed 
by  absorption  within  the  boundaries  of  the  adhering  structures; 
the  abscess  then  protrudes;  and  extravasation  of  pus  at  the  mar- 
gins is  prevented  from  taking  place  by  the  firm  union  of  the  parts  en- 
circling the  opening.  .  .  .  The  abscess  comes  into  relation  with  the 
heads  of  the  psoas  muscle.  .  .  .  But  as  it  travels  downward,  it  is  pre- 
vented from  enlarging  in  the  fore  part,  by  the  resistance  from  the 
ligamenta  arcuata,  and  at  the  back  by  that  of  the  spine  and  the 
lowest  rib;  hence  it  forces  its  way  in  the  line  of  the  psoas  muscle." 
In  this  way  the  muscles  may  become  involved  in  the  suppuration 
and  constitute  a  part  of  the  abscess. 

The  abscess  tends  to  enlarge  more  on  its  outer  than  on  its  inner 
side  because  the  fascia  is  less  resistant  there.  It  finally  reaches 
Poupart's  ligament  and  bulges  in  the  groin.  The  pus  may,  how- 
ever, travel  as  far  down  as  the  insertion  of  the  psoas  muscle. 
There  is  then  a  swelling  both  above  and  below  Poupart's  ligament 
and  fluctuation  may  be  detected  between  the  two  by  placing  one 
finger  above  the  ligament  and  the  other  below  it. 

Pus  may  find  its  way  to  the  iliac  fossa  either  from  a  psoas  abscess 
or  by  finding  its  own  way  there  directly  from  the  diseased  bodies. 
At  times  a  collection  of  pus  will  work  over  the  crest  of  the  ilium 
and  point  in  the  gluteal  region. 

A  lumbar  abscess  is  the  outcome  of  disease  of  the  lumbar  verte- 
brae. It  appears  as  a  swelling  on  one  side  or  the  other  just  outside 
the  quadratus  lumborum.  At  times  it  is  associated  with  dorsal 
caries  and  not  with  lumbar. 

Abscesses  may  accumulate  in  the  inguinal  region  above  Pou- 
part's ligament.  Before  passing  down  the  sheath  of  the  psoas 
muscle,  they  may   enlarge   in   the   abdominal   cavity  beneath   the 


32 


ORTHOPEDIC  SURGERY. 


peritoneum,  constituting  a  layer  of  subperitoneal  abscesses.  In 
time  these  abscesses  descend  down  the  thigh,  but  they  may  remain 
for  a  long  time  large,  threatening,  abdominal  tumors. 

Before  the  Royal  Medical  and  Chirurgical  Society  Mr.  R.  W. 
Parker '  said  that  out  of  one  hundred  and  eighty-three  cases  of 
caries    of    the    spine,  he    found    nine    cervical,   eighty-two    dorsal, 

twenty-one  dorso-lumbar,  thirty-seven 
lumbo-sacral,  and  in  forty-two  cases  the 
position  was  not  noted. 

In  about  eight  per  cent  of  his  dorsal 
cases  suppuration  ensued,  while  it  was 
found  in  thirty  per  cent  of  his  dorso-lum- 
bar cases  and  in  seventy  per  cent  of  the 
lumbo-sacral. 

Abscesses,  however,  at  times  point  in 
all  sorts  of  places.  They  may  burst  into 
the  mouth,  trachea,  or    bronchi,^  in    the 


Fig.  49. — Lumbar  Abscess, 


Fig.  50. — Retro-Pharyngeal  Abscess,  showing  Character- 
istic Expression  and  Attitude. 


intestines,  bladder,  or  the  abdominal  cavity.  Dissecting  behind 
the  pharynx  they  cause  dyspncea,  the  result  of  the  bulging  of  the 
posterior  wall,  and  are  recognized  as  retro-pharyngeal  abscesses. 
Occasionally  they  burst  in  the  alimentary  canal,  not  so  rarely  in 
the  lungs,  and  exceptionally  in  the  peritoneum  or  larger  vessels. 
Sometimes  apparently  the  sac  descends  on  both  sides  of  the  spinal 
column,  developing  two  abscesses. 

'  British  Medical  Journal,  January  12th,  1884,  p.  58. 

^Cossy,  Bull.  Soc.  Anat.,  1877,541,  and  Gamlet,  Bull.  Soc.  Anat.,  1878. 


POTT'S    niSI'lASI']. 


3,3 


The  contents  of  abscesses  vary.  Usually  they  are  filled  with 
serous  or  sero-purulent  fluid,  with  caseous  masses.  Soinetinnes  the 
contents  may  be  entirely  cheesy.  Often  they  contain  fra^'ments  of 
necrotic  bone  and  small  calcified  masses  with  large  shreds  and 
flakes  of  gelatinous  material  from  the  suppurating  tissues.  This  is 
of  practical  importance  in  the  question  of  aspiration  of  these  ab- 
scesses, for  the  shreds  and  flakes  in  the  pus  are  likely  to  form  an 
obstruction  to  the  passage  of  the  pus  through  any  needle  save  a 
very  large  one. 

Pallor,  impairment  of  strength,  or  an  increase  in  the  number  of 
the  white  corpuscles,  with  a  diminution  of  the  number  of  red, 
justify,  if  existing  for  some  time,  an  opinion  of  the  existence  of  a 
collection  of  pus.  The  local  symptoms  presented  by  abscesses 
vary  with  the  locality.  Retro-pharyngeal  abscesses  cause  dyspnoea 
and  dysphagia.  Abscesses  in  the  lung  give  rise  to  less  disturbance 
than  would  be  supposed ;  in  reality  they  present  the  rational  and 
physical  signs  of  a  low  form  of  localized  pneumonia,  of  a  chronic 
or  subacute  type.  The  bursting  of  an  abscess  into  the  bronchi  is 
characterized  by  the  discharge  of  a  large  quantity  of  pus,  which  is 
coughed  up,  the  amount  of  dyspnoea,  collapse,  and  danger  -from 
suffocation  being  dependent  on  the  size  of  the  abscess.  The  sud- 
den discharge  of  pus  is  the  indication  of  rupture  into  the  oesopha- 
gus, intestines,  and  bladder;  rupture  into  the  peritonenm  or  com.- 
munication  with  large  vessels  will  necessarily  be  fatal,  and  there 
are  no  symptoms  which  will  give  warning  of  the  impending 
danger. 

The  course  of  an  abscess  is  toward  absorption  or  increase.  It 
may  remain  stationary  in  size  and  quiescent  for  a  long  time — -a  con- 
dition of  things  which  may  be  compatible  with  fair  general  health. 
Instances  are  not  uncommon  where  adults  have  been  able  to  attend 
to  active  work  and  children  to  play  about,  although  suffering  from 
a  large  cold  abscess. 

When  absorption  takes  place,  the  fluid  contents  disappear,  and 
the  caseous  and  purulent  detritus,  if  present,  in  all  probability  be- 
comes encapsuled.  This  sometimes  happens,  even  in  quite  large 
abscesses. 

When  the  abscess  is  evacuated,  there  is  as  a  rule  but  slight  gen- 
eral disturbance,  provided  it  bursts  in  such  a  way,  and  the  abscess 
itself  is  in  such  a  condition,  as  to  give  complete  drainage;  if  it  is 
only  evacuated  in  part,  and  if  the  cavity  of  the  abscess  is  large,  ex- 
tending upward  to  the  spinal  column  by  means  of  a  long  circuitous 
channel  which  does  not  admit  of  complete  drainage,  fever,  with 
septic  changes,  usually  follows  the  evacuation  of  the  abscess,  vary- 
ing in  different  cases  in  amount  and  extent. 
3 


34 


ORTHOPEDIC  SURGERY. 


Michel  found,  in  48   cases  of  abscess,  the  locahzation  to  be  as 
follows: 

In  39  the  abscess  was  about  the  pelvis ;  in  6  it  was  in  the  neck, 
and  in  3  it  was  in  the  dorsal  region;  of  the  39  in  the  pelvis  13  were 
about  the  groin,  14  occupied  the  iliac  fossa  (2  of  these  occupied 
the  upper  outer  part  of  the  thigh  in  addition),  and  i  appeared  near 
the  anterior  superior  spine  of  the  ilium ;  7  were  in  the  lumbar 
region;  i  in  the  perineum;  of  the  6  in  the  neck  i  was  in  the  supra- 
clavicular fossa,  3  at  the  sides  of  the  neck, 
and  2  were  post-pharyngeal.  The  3  ab- 
scesses in  the  dorsal  region  appeared  near 
the  middle  line  and  by  the  sides  of  the  dis- 
eased vertebrae. 

Abscesses  may  burst  directly  into  the 
spinal  canal,  or  into  the  hip-joint,  giving  rise 
to  hip-disease,  or  may  appear  in  the  ingui- 
nal canal,  simulating  hernia. 

Parker  {Brit.  Med.  Jotir.,  January  12th, 
1884,  p.  78)  found,  in  an  examination  of  82 
dorsal,  21  dorso-lumbar,  and  37  lumbo-sacral 
cases  of  spinal  caries,  abscesses  in  eight  per 
cent  of  the  dorsal  cases,  in  thirty  per  cent 
of  the  dorso-lumbar  cases,  and  in  seventy 
per  cent  of  the  lumbo-sacral. 

As  a  rule  abscesses  which  burst  spontane- 
ously are  very  likely  to  discharge  from 
pouting  sinuses,  for  an  indefinite  time,  often 
for  years.  This  tendency  seems  to  be  di- 
minished by  thorough  operative  treatment 
of  the  abscesses,  establishing  perfect  drain- 
age, but  even  then  the  seat  of  disease  is 
often  inaccessible  and  for  a  long  time  the 
abscess  cavity  may  discharge  from  sinuses. 
Furthermore,  a  tuberculous  condition  of  the  sinus  wall  may  be 
developed  and  the  sinus  itself  may  become  a  tissue  secreting  pus. 

General  Condition. — Pott's  disease  produces  a  more  profound  im- 
pression upon  the  general  condition  than  do  the  other  tuberculous 
joint  and  bone  diseases.  Children  with  Pott's  disease  may  be 
noticeably  retarded  in  the  growth  of  their  trunks  and  may  become 
dwarfed.  The  arms  and  the  legs  seem  abnormally  long,  and  the 
head  also  seems  unusually  large.  These  children  are  frequently 
fretful  and  capricious,  made  so  either  by  the  disease  and  by  ill- 
health  or  by  injudicious  petting  on  the  part  of  the  family.  They 
are  also  often  precocious  and  their  mental  development  is  superior 


Fig. 


51. — Showing  Disproportion 
of  Head  and  Trunk. 


J'OTTS   J)/SJ':/1SJC. 


35 


to  healthy  children  of  the  same  a^^e.  Tlicy  arc,  moreover,  delicate, 
take  cold  easily  and  seem  especially  liable  to  slight  attacks  of 
pneumonia.  Heart  disease  also  seems  frequent  amon^  them,  and 
disturbances  of  the  digestion— ^mvj'  gasti'icpics.  Patients  with 
Pott's  disease  are  of  course  liable  to  attacks  of  tubercular  menin- 
gitis, but  the  experience  of  the  writers  would  lead  them  to  believe 
that  the  liability  to  this  was  less  than  in  hip-joint  disease. 

The  temperature  in  Pott's  disease  is  in  general  higher  than  in 
health.  In  hip  disease  the  same  holds  true,  and  the  number  of 
cases  considered  in  that  connection  is  larger  than  the  number 
noted  here.  The  following  temperatures  were  taken  in  cases  of 
Pott's  disease  treated  without  recumbency,  in  all  stages  of  the  dis- 
ease, when  the  affection  was  at  all  marked.  The  hectic  appearance 
of  these  children  as  seen  late  in  the  afternoon  suggested  the 
likelihood  of  a  higher  temperature  than  normal.  The  temper- 
atures were  all  taken  with  a  standardized  thermometer.  99.5°, 
100.3°,  997°>  100.9°,  99-3°»  99-3%  100.5°,  101.1°,  99.3°,  98.7°,  100.9° 
F.  Healthy  children  under  the  same  conditions  had  normal  tem- 
peratures. 


Diagnosis. 

The  recognition  of  Pott's  disease  in  the  later  stages  is  easy, 
but  before  the  presence  of  the  sharp  projection,  or  while  that 
is  still  small,  the  affection  is  often   overlooked.     In  examining  a 


Rigidity  of  the  Spinal  Column  in  Pott's  Disease. 


suspected  case  in  the  early  stage  a  diagnosis  is  to  be  based  on  the 
presence  of  the  following  symptoms:  i,  stiffness  in  the  back;  2, 
peculiarity  of  attitude  or  gait;    3,  seat  and  localization  of  pain  and 


36 


ORTHOPEDIC  SURGERY. 


nervous  symptoms ;  4,  irregularity  of  outline  of  the  row  of  spinous 
processes,  or  abnormal  projection  of  individual  spinous  processes. 

The  child  should  be  entirely  undressed  for  examination  and 
made  to  stand  on  a  table  or  upon  the  floor  and  to  walk  across  the 
room.  This  proceeding  will  perhaps  reveal  some  peculiarity  of 
gait  or  position  which  will  not  be  evident  in  any  other  way.  The 
child  should  then  be  carefully  inspected  as  to  the  outline  of  the 
spinous  processes  and  made  to  pick  up  some 
object  from  the  floor.  During  the  movement 
the  surgeon  should  note  the  rigidity  of  the  back, 
if  any  such  symptom  present.  The  patient 
should  then  be  laid  upon  his  face  on  a  table 
or  bed  and  the  outline  of  the  spinous  processes 
examined  with  the  fingers.  The  flexibility  of 
the  column  should  next  be  tested  by  lifting  the 
child  by  the  feet  while  it  lies  face  downward  on 
a  table. 

In  Pott's  disease  the  back  is  rigid,  as  shown 
in  the  figure,  taken  from  a  case  of   moderately 
acute  Pott's  disease  in  the  dorsal   region.     Gen- 
erally the  erector  spinae  muscles  can 
be  seen  standing  out  like  cords  on  both 
sides  of  the  spinous  processes 
endeavor  to  hold  the 


Fig.  53. — Normal  Flexibility  of  Spinal  Column. 

The  normal  flexibility  of  the  column  is  shown  in  Figs.  53  and  54. 

Psoas  contraction  is  looked  for  by  placing  one  hand  on  the 
sacrum  and  hyperextending  one  leg  and  then  the  other  (Fig.  33). 
When  cervical  caries  is  suspected,  the  movements  of  the  head  must 
be  tested.  With  adults  this  examination  has  to  be  modified  to  a 
certain  degree  and  voluntary  movements  on  the  part  of  the  patient 
must  in  a  measure  be  substituted  for  passive  manipulation. 

I.  MiLsailar  Stiffness. — In  the  very  early  stage  of  Pott's  disease 
the  most  reliable  diagnostic  signs  must  always  be  the  rigidity  of 


POTT'S  JJ  IS  EASE. 


37 


the  vertebral  column  at  the  seat  of  disease.  This  may  often  be 
brought  out  by  passive  manipulation  when  the  characteristic  atti- 
tudes have  not  yet  been  assumed.  If  the  child  walks  with  unusual 
stiffness  or  keeps  the  back  stiff  in  stooping  or  j^resents  even  a  very 
small  angular  prominence,  the  diagnosis  is  all  the  more  clear,  but 
observant  parents  bring  children  to  the  surgeon  before  these  things 
have  occurred  and  the  recognition  of  muscular  rigidity  becomes  a 
matter  of  prime  importance. 

To  recognize  this  it  is  important  to  know  the  amount  of  normal 
flexibility  of  the  spinal  column.  This  varies  to  a  degree  in  indi- 
viduals, and  in  children  is  much  greater  than  in  adults.  Little  dif- 
ficulty is  met  in  recognizing  muscular  stiffness  in  the  cervical 
region.  The  normal  flexibility  of  the  spinal  column  can  be  tested 
as  follows :  The  child  should  sit  upon  a  lounge  with  legs  bent 
slightly  at  the  knee,  and  touch  the  toes  with  both  hands,  at  the 
same  time  placing  the  chin 
upon  the  sternum;  or,  stand- 
ing with  straight  legs  and 
arms  stretched  out  above  the 
head,  the  child  should  en- 
deavor to  touch  the  floor 
with  the  hands,  curving  the 
head  upon  the  chest  as  far  as 
is  possible. 

To    determine  stiffness  of 

the  qUadratUS  lumborum  and  ^'^-  54.-Normal  Flexion  of  Spinal  Column. 

psoas  and  iliacus  muscles,  the  child  should  be  placed  upon  the  face 
and  an  attempt  be  made  to  raise  the  thighs.  Normally  the  spine 
can  be  bent  to  a  marked  degree,  the  back  sagging  as  the  thighs  are 
raised  in  this  way;  in  diseases  of  the  lower  dorsal  or  lumbar  region 
the  whole  trunk  will  be  lifted  as  if  made  in  one  piece,  on  lifting 
the  thighs  (  Fig.  52). 

Stiffness  of  the  back  is  an  early  and  a  well-marked  symptom ;  it 
may  be  unrecognizable  in  the  earliest  stages  of  lumbar  caries,  if 
the  disease  is  localized  in  a  small  focus,  not  yet  involving  the  carti- 
lage or  whole  of  the  vertebral  body.  Stiffness  may  be  confined  to 
a  few  of  the  adjacent  vertebrae  and  not  involve  the  whole  back, 
i.e.,  patients  with  cervical  or  upper  dorsal  caries  in  a  subacute  stage 
may  be  able  to  stoop  to  the  floor  quite  freely,  without  indicating 
any  lack  of  mobility  in  the  lumbar  or  lower  dorsal  region.  Stiff- 
ness of  the  upper  dorsal  vertebrae,  if  limited  to  a  small  region 
and  slight  in  amount,  is  with  difficulty  noticed,  as  normally  there 
is  not  much  flexibility  in  the  upper  thoracic  region ;  but  for 
practical  purposes,  in  the  usual  cases  which  present  themselves  for 


38  ORTHOPEDIC  SURGERY. 

examination,  the  amount  of  stiffness  is  such  that  it  admits  of  no 
mistake. 

In  such  a  case  when  a  child  is  Hfted  by  the  heels,  as  shown  in 
the  figure,  the  erector  spinae  muscles  will  often  stand  out  on  each 
side  of  the  spine  as  indistinct  and  very  firm  columns. 

In  cervical,  and  occasionally  in  upper  dorsal,  disease  the  spasm 
of  the  muscle  produces  a  torticollis  which  is  sometimes  with  difB- 
culty  distinguished  from  pure  torticollis  (independent  of  any  dis- 
ease of  bone). 

In  torticollis  from  caries  the  posterior  muscles  rather  than  the 
sterno-mastoid  are  usually  involved,  and  there  is  more  spasm  than 
is  usual  in  simple  torticollis.  The  patient,  in  lying  down  or  in  sit- 
ting up  suddenly,  usually  steadies  or  supports  the  head  with  the 
hands  as  a  protection  against  jar  or  violence.  If  there  is  pain,  it  is 
in  the  back  of  the  head  or  shoulders.  In  pronounced  cases  there 
is  little  difBculty  in  recognizing  cervical  caries — ^there  is  a  thicken- 
ing and  a  projection  in  the  outline  of  the  neck,  the  back  is  flattened 
between  the  shoulders,  or  even  hollowed  in,  with  a  compensatory 
projection  in  the  spine  in  the  lumbar  region;  sometimes  in  upper 
cervical  disease  a  projection  of  the  pharynx  is  to  be  felt  in  the 
mouth. 

In  examining  for  peculiarity  of  gait,  attitude,  and  movement,  as 
mentioned  above,  the  child  should  be  watched  narrowly  as  it  runs 
about,  rises  from  a  recumbent  position,  stoops,  etc.  In  the  earliest 
stages  the  variation  from  normal  movement  may  be  slight  at  times. 

The  nervous  disturbances  are,  as  has  been  mentioned,  those  de- 
pendent on  irritation  of  the  nerves  issuing  from  the  column  at  the 
affected  point,  and  on  a  transverse  meningitis  or  meningo-myelitis, 
They  consist  of  pseudo-neuralgias,  cough,  grunting  respiration,  or 
dyspeptic  attacks. 

2.  Peculiarity  of  Attitude  and  Gait. — The  peculiar  attitudes  and 
gait  of  persons  with  Pott's  disease  have  been  so  fully  considered 
already  in  their  diagnostic  bearing  that  there  is  no  occasion  to 
repeat  them  here.  They  are  early  symptoms  of  the  disease  and 
they  precede  the  formation  of  a  knuckle  in  the  back,  but  they  fol- 
low muscular  rigidity,  which  is  the  earliest  symptom  of  all.  The 
diagnosis  must  not  rest  on  attitude  alone  in  a  doubtful  case,  unless 
it  is  confirmed  by  muscular  stiffness  at  the  affected  part.  At  other 
times  too  much  stress  must  not  be  laid  upon  the  absence  of  charac- 
teristic attitudes.  One  occasionally  sees  children  with  well-marked 
kyphosis  who  do  not  present  any  characteristics  of  gait  or  attitude. 

3.  Seat  and  Localization  of  Pain  and  Nervous  Symptoms. — Pain 
is  not  a  necessary  accompaniment  of  Pott's  disease  ;  when  it  oc- 
curs it  is  generally  referred  to  the  back  of  head,  shoulders,  chest. 


POTT'S    1)  1ST: ASK.  30 

abdomen,  or  legs,  rather  than  to  the  back.  It  is  increased  by  jars 
and  by  the  erect  position.  It  may  occur  in  the  form  of  "night 
cries,"  and  at  other  times  it  may  appear  as  a  spasmodic  abdominal 
pain  during  the  daytime,  much  resembling  cramps.  Sometimes  it 
is  excited  if  the  child  be  lifted,  as  described  above,  to  see  if  there 
is  muscular  stiffness  present,  but  in  other  cases  with  perfect  stiff- 
ness of  the  back,  pain  is  wholly  absent.  The  test  of  pressing  down 
on  the  child's  head  to  see  if  pain  is  caused  in  the  back  is  a  brutal 
and  irrational  one.  Tenderness  on  pressure  over  the  spine  is 
almost  never  present,  although  it  is  spoken  of  in  many  text-books  as 
characteristic  of  the  disease.  This  is  so  much  the  case  that  ten- 
derness when  present  is  more  an  evidence  of  a  functional  neurosis, 
or  hysterical  spine,  than  it  is  of  caries.  A  tenderness  in  the  spine 
may  occasionally  be  present  in  Pott's  disease,  from  a  hyperesthe- 
sia of  nerves,  but  even  this  is  rare. 

Paralysis,  as  another  nervous  symptom,  is  sometimes  the  first  to 
be  noted.  This  is  not  a  common  event,  but  sometimes  in  a  doubt- 
ful case  the  occurrence  of  paralysis  is  suf^ficient  to  settle  the  ques- 
tion of  diagnosis.  A  recognition  of  the  beginning  of  paralysis  is 
usually  possible,  from  the  fact  that  it  is  generally  preceded  by  an 
increase  of  pain  in  the  abdomen,  and  an  increase  of  the  deep  re- 
flexes of  the  knee  and  ankle,  and  by  muscular  cramps.  The  paral- 
ysis usually  begins  gradually,  and  is  first  indicated  by  the  patient's 
dragging  one  of  his  legs.  But  even  before  that  it  is  generally 
noticed  that  the  patient  becomes  tired  very  easily  and  seems  weak. 

A  peculiarity  in  breathing  is  particularly  noticeable  in  upper  and 
middle  dorsal  caries  in  the  acute  or  subacute  stage.  The  patient 
breathes  as  if  unable  to  take  a  long  breath,  and  while  talking  or 
breathing  rapidly  will  hold  the  breath  momentarily.  The  respira- 
tion has  been  defined  as  a  grunting  respiration,  which  expresses 
the  condition  well. 

4.  Irregularity  of  Outline  of  the  Roiv  of  Spinous  Processes  or  Ab- 
normal Projection  of  the  Individtial  Spinojis  Processes. — The  recog- 
nition of  a  projecting  knuckle  in  the  earliest  stages  of  caries  of 
the  spine  is  not  so  easy  as  might  be  supposed.  In  very  young 
children,  when  fat,  the  spinous  processes  are  not  easily  felt,  and 
furthermore,  a  projection  may  sometimes  be  seen  normally,  in 
thin  subjects,  of  the  spines  of  the  sixth  and  seventh  cervical,  occa- 
sionally of  the  first  dorsal  and  also  of  the  last  dorsal  and  the  first 
and  second  lumbar  vertebrae. 

These  normal  projections  differ  from  the  sharp  projection  seen 
in  caries,  in  that  they  are  in  conformity  with  the  projections  of  the 
other  spinous  processes — and  more  like  a  longer  spinous  process 
and  less  like  a  spine  projecting  at  a  wrong  angle.     Any  projection 


40 


ORTHOPEDIC  SURGERY. 


beyond  the  line  of  the  other  spinous  processes  of  a  spine  in  the 
middle  dorsal  region,  must  be  regarded  as  presumptive  evidence 
of  caries,  inasmuch  as  a  physiological  projection  in  the  upper  and 
middle  dorsal  regfon  (below  the  first  two  dorsal)  has  not  been 
observed  in  children. 

Irregular  and  pathological  projections  in  the  upper  cervical 
region  are  in  the  early  stages  difficult  to  recognize,  owing  to  the 
thickness  of  the  overlying  muscles;  a  diagnosis  is  here  rather  to 
be  based  on  the  position  of  the  head  and  the  muscular  spasm.  The 
shape  of  the  back  varies  in  adults  physiologically — the  back  of  a 
cobbler  is  different  in  curve  from  that  of  a  soldier,  and  projections 
in  the  lower  dorsal  and  upper  lumbar  regions  may  be  seen  in 
healthy  backs. 

The  Diagnosis  of  Abscesses. — Abscesses  may  remain  some  time 
without  being  recognized,  when  in  the  thorax  or  abdomen.  Ordi- 
narily, however,  they  pass  down  the  sheath  of  the  psoas  muscle, 
and  the  irritation  excited  by  the  presence  of  inflammatory  invasion 
causes  muscular  spasm  and  a  contraction,  more  or  less  marked,  of 
the  psoas  muscle ;  this  is  shown  by  a  peculiarity  in  gait  and  by 
limitation  in  extension  of  the  thigh.  Induration  and  fluctuation 
can  be  felt  in  the  lower  abdomen  above  Poupart's  ligament,  on 
deep  pressure,  often  before  a  swelling  is  noticeable  to  the  eye. 

The  formation  of  an  abscess  may  be  suspected  when  pain  sud- 
denly increases,  and  a  patient  who  has  been  doing  well  loses  flesh 
and  shows  other  signs  of  general  disturbance. 

Retro-pharyngeal  abscesses  are  recognized  by  the  symptoms  of 
dyspnoea,  and  on  palpation  a  fluctuating  projection  will  be  felt  in 
the  pharynx. 

The  occurrence  of  swelling  should  be  watched  for  in  such  cases. 
In  Pott's  disease  of  the  dorsal  and  lumbar  region  this  is  likely  to 
appear  in  the  lumbar  region  or  the  groin,  and  it  may  be  noted  that 
contraction  of  the  psoas  muscle,  and  consequent  inability  to  ex- 
tend the  leg  fully,  is  frequently  a  precursor  of  this  condition. 

The  amount  of  the  psoas  contraction  in  these  cases  and  its  oc- 
curence probably  depends  somewhat  upon  the  course  of  the  abscess, 
and  the  consequent  irritation  of  the  psoas  muscle.  In  some  cases 
the  contraction  is  very  severe  and  occasions  a  distressing  deform- 
ity. In  other  instances  the  contraction  can  be  determined  only  by 
careful  examination.  The  character  of  the  deformity  has  already 
been  alluded  to  in  speaking  of  attitude. 

Hernia  is  sometimes  suggested  by  the  appearance  of  a  psoas 
abscess  in  the  groin.  Such  purulent  collections  sometimes  appear 
very  suddenly,  are  egg-shaped  and  not  hot  or  tender.  They  can 
sometimes  be  much  diminished  in  size  by  gentle  pressure,  but  they 


POTT'S  J)  IS  EASE.  4 1 

at  once  refill  and  present  none  of  the  characteristic  features  of 
hernia.  They  lie  outside  of  the  femoral  vessels  in  general  and  the 
signs  of  Pott's  disease  are  always  present. 

The  finer  diagnostic  points  are  needed  in  less  pronounced  cases, 
of  Pott's  disease,  but  ordinarily  the  disease  presents  itself  witii 
well-marked  characteristics,  even  in  the  earlier  stages. 

The  patient,  usually  a  child,  is  brought  for  examination  with  the 
statement  that  there  are  occasionally  sharp  pains  in  the  belly, 
colicky  pains,  or  rheumatism  in  the  legs,  that  this  pain  is  increased 
by  jar,  that  riding  aggravates  the  symptoms ;  there  is  stiffness  after 
getting  up  out  of  bed,  or  after  sitting  for  a  while,  and  it  requires 
some  little  running  about  before  the  stiffness  passes  away.  The 
child  will  occasionally  stop  in  its  play,  and  will  lie  down  or  com- 
plain of  pain,  which  may  be  only  temporary.  On  examining  the 
child  without  clothes,  it  will  be  found  that  there  is  a  peculiarity  in 
gait  or  attitude ;  the  child  walks  stififly,  with  short  steps,  bent 
knees,  with  head  erect,  chin  thrust  forward,  and  shoulders  raised ; 
sits  rather  than  stoops  in  picking  anything  from  the  floor.  The 
child  leans  against  a  chair  as  if  tired,  and  supports  the  head  with 
the  hand;  if  lying  down  it  gets  up  slowly  and  carefully,  and  stands 
with  its  hands  on  its  thighs.  There  is  often  a  grunting  respiration 
and  monosyllabic  speech,  as  if  deep  breathing  jarred  the  spine,  a 
symptom  almost  pathognomonic  of  the  disease.  An  abnormal 
projection  of  one  or  two  of  the  spines  of  the  vertebrae,  with  stiff 
ness,  completes  the  diagnosis,  and  to  this  is  often  added  spasmodic 
action  of  the  muscles  of  the  back,  which  start  out  on  jarring  the 
spine  and  are  quite  noticeable  on  inspection. 

History. — The  question  of  diagnosis  in  Pott's  disease  must  not 
be  dismissed  without  a  word  as  to  the  little  dependence  that  can 
be  placed  upon  the  previous  history  of  the  case  as  presented  by 
the  average  parent.  There  is  an  almost  universal  tendency  to 
refer  the  disease  to  some  slight  accident  and  to  date  the  beginning 
of  the  disease  from  that.  Often  enough  it  is  evident  that  the 
disease  is  of  long  standing  and  that  the  recent  accident  has  only 
served  to  direct  the  parent's  attention  to  a  condition  in  the  back 
which  was  present  in  a  considerable  degree  before  that. 

The  diagnosis  must  be  made  and  can  usually  be  made  from  the 
physical  signs.  The  history  of  the  case,  as  often  given,  cannot  be 
allowed  undue  importance. 

Noble  Smith  calls  attention  to  the  frequency  with  which  Pott's 
disease  is  overlooked  by  the  medical  man,  and  tells  of  some  re- 
markable specimens  to  be  found  in  the  London  Hospitals,  where 
extensive  destruction  of  the  vertebrae  had  taken  place,  and  yet 
when  the  symptoms  during  life  had  been  most  insignificant.     Nota- 


42 


ORTHOPEDIC  SURGERY. 


bly  that  of  Dean  Buckland,  whose  symptoms  were  those  of  "  mel- 
ancholia," where  after  death  there  was  found  extensive  caries  of 
the  first  three  cervical  vertebrae. 


Differential  Diagnosis. 

It  is  difificult  at  times  to  differentiate  a  strain  of  the  vertebral 
coliLvin  from  Pott's  disease.  After  a  fall  in  which  the  back  has 
been  wrenched,  a  child  begins  to  walk  stiffly  and  to  complain 
of  pain-  in  the  back  and  perhaps  in  the  legs.  Attitudes  char- 
acteristic  of    Pott's   disease   are   assumed,  the  trunk   is   supported 


Fig.  55. — Rhachitic  Curvature  of  the  Spine. 

with  the  hands  upon  the  thighs,  the  back  is  kept  stiff  in  stoop- 
ing, and  passive  manipulation  shows  that  muscular  rigidity  is 
present.  This  condition  has,  perhaps  existed  for  ten  days  and  an 
opinion  is  requested  as  to  the  existence  of  serious  trouble.  At  this 
stage  a  diagnosis  is  sometimes  clearly  impossible.  But  in  strains  of 
the  back  the  tendency  is  to  a  recovery,  and  the  result  establishes 
the  diagnosis.  Severe  strains  of  the  back  are  comparatively  rare 
in  childhood,  but  in  adult  males  engaged  in  laborious  occupation 
cases  of  strain  are  more  common  than  cases  of  Pott's  disease. 
The  diagnosis  is  one  which  should  be  made  in  childhood  with  very 
great  reserve. 

Rhachitic  curvature  of  the  spine  is  often  with  difficulty  distin- 
guished from  Pott's  disease.     It  will  be  noticed  in  the  figures  that 


POTT'S  J)ISEASE. 


43 


the  bend,  usually  described  as  involving  the  whole  column,  may 
be  almost  angular  and  present  the  closest  resemblance  to  a  yielding 
of  the  column  produced  by  carious  softening.  Rhachitic  curva- 
ture, however,  occurs  in  young  children,  who  present  more  or  less 
marked  signs  of  general  rickets,  although  they  may  be  slight.  It 
is  situated  at  the  junction  of  the  lumbar  and  dorsal  regions  and 
involves  several  vertebra;.  Muscular  rigidity  is  not  so  common  or 
so  marked  as  in  Pott's  disease,  but  it  may  be  present  to  almost 
complete  fixation,  all  statements  to  the  contrary  notwithstanding, 
and  muscular  stiffness  cannot  be  relied  upon  as  a  sign  that  what 
seems  to  be  a  rhachitic  curvature  is  really  Pott's  disease. 

Lateral  curvature  of  the  spine  is  an  entirely  different  affection  from 


Fig.  56. — Rhachitic  Curvature  of  the  Spine. 


Pott's  disease.  It  is  not  the  result  of  a  carious  destruction  of  bone, 
but  is  the  result  of  a  distorted  and  abnormal  process  of  growth. 
It  is  characterized  not  by  an  angular  projection  of  the  spine  back- 
ward, but  by  a  gradual  shaped  curve  of  the  spine  laterally  with  a 
rotation  of  the  vertebral  column  on  its  long  axis,  as  described 
in  Chapter  II.  Pain  is  not  present,  and  the  recognition  of  the 
affection  is  generally  due  to  an  alteration  in  the  outlines  of  the 
trunk,  and  a  prominence  of  the  shoulder  or  hip,  as  mentioned  in 
Chapter  II. 

Lateral  deviation  of  the  spine  which  accompanies  Pott's  disease 
is  not  so  much  characterized  by  rotation  of  the  ribs.  It  may  be 
present  as  an  early  symptom,  but  it  often  occurs  late,  and  other 
symptoms  of  the  disease  are  generally  well  marked,  and  as  a  rule 


44 


ORTHOPEDIC  SURGERY. 


it  accompanies  severe  and  painful  cases.  It  is  much  diminished  by 
recumbency,  and  the  other  signs  of  Pott's  disease  are  present. 
Pott's  disease  and  true  rotary  lateral  curvature  practically  never 
coexist,  and  in  most  cases  the  diagnosis  is  not  at  all  obscure.  But 
in  the  course  of  Pott's  disease  at  an  early  stage  a  lateral  deviation 
may  be  present,  which  may  be  mistaken  for  lateral  curvature.  On 
a  careful  examination  it  will,  however,  be  found  that  a  stiffness  of 
the  back  is  present  which  is  never  to  be  seen  at  an  early  stage  of 


Fig.  57. — Front  View  of  the  Lateral  Deviation  in 
Pott's  Disease. 


Fig.  58. — Lateral  Curvature  from  Severe  Pott's  Dis- 
ease and  Psoas  Contraction  of  Right  Side. 


lateral  curvature.  In  some  instances  careful  and  repeated  exam- 
inations are  needed  to  establish  a  positive  opinion. 

A  lateral  deviation  takes  place  also  sometimes  in  old  cases  of 
caries  of  the  spine  in  connection  with  an  old  kyphotic  curve.  The 
condition  is,  however,  so  easily  recognized  that  a  mistake  in  diag- 
nosis is  not  possible. 

Wry  neck  may  be  a  symptom  of  cervical  Pott's  disease,  and  the 
diagnosis  between  true  muscular  wry  neck  and  the  distortion  which 
is  only  symptomatic  of  bone  trouble  is  one  which  often  requires 
the  closest  attention.     At  other  times  one  has  to  wait  for  the  de- 


POTT'S   DISEASE. 


45 


velopment  of  farther  symptoms.  True  wry  neck  is  caused  chiefly 
by  the  contraction  of  certain  muscles  of  the  neck,  tlie  other  mus- 
cles being  unaffected.  Movement  of  the  head  is  free  in  all  other 
directions,  there  is  no  pain  and  no  resistance  to  passive  motion  on 
the  part  of  the  other  muscles. 

On  the  other  hand,  wry  neck  due  to  caries  resembles  at  first 
sight  the  condition  just  mentioned  very  closely,  but  pain  is  gener- 
ally present  and  the  head  is  held  firmly  in  its  abnormal  position 
by  all  the  muscles.  In  fact  the  deep  muscles  seem  more  firmly  set 
than  the  superficial  ones.  Any  attempt  at  passive  motion  of  the 
head  excites  resistance  of  all  the  muscles  of  the  neck,  which  all 
guard  the  position  and  render 
further  movement  painful. 

When  torticollis  is  merely  sym.p- 
tomatic,  the  gait  is  often  stiff, 
and  the  head  is  perhaps  held 
with  the  hand  under  the  chin. 
The  back  of  the  neck  is  also  flat- 
tened, and  in  general  the  other 
symptoms  of  cervical  Pott's  dis- 
ease coexist. 

Hip  disease  under  certain  con- 
ditions may  be  confounded  with 
lumbar  caries  of  the  spine.  In 
certain  cases  of  hip  disease  in  an 
acute  stage  there  is  muscular  re- 
sistance to  motion  in  the  lower 
dorsal  and  lumbar  region,  just 
as  a  prevention  of  motion  at  the  ' 
hip  joint  analogous  to  the  psoas  F1G.59 
and  lumbar  stiffness  is  found  in 
lower  Pott's  disease.  In  hip  disease  this  stiffness  is  also  to  be 
found  to  a  marked  degree  in  the  adductor  muscles  of  the  thigh, 
while  in  Pott's  disease,  unless  a  psoas  abscess  has  directly  invaded 
the  periarticular  tissues  of  the  hip  joint  and  is  irritating  the  peri- 
articular muscles,  motion  is  no  more  limited  in  the  direction  of  the 
adductor  than  in  any  group  of  muscles. 

In  brief,  it  may  be  said  that  in  hip  disease,  even  at  the  earliest 
stage,  there  is  restricted  motion  in  all  directions  of  the  normal 
movements  of  the  hip  joint — a  symptom  not  present  in  lumbar 
caries.  In  the  latter,  however,  stiffness  of  the  back  is  always  pres- 
ent, while  the  resistance  at  the  hip  is  usually  to  the  motion  of  ex- 
tension of  the  thigh  to  a  greater  degree  than  to  that  of  flexion 
or  abduction. 


Lateral  Distortion  of  the  Column  in  a  Severe 
Case  of  Dorsal  Disease. 


46  ORTHOPEDIC  SURGERY. 

In  some  cases  repeated  and  careful  examinations  are  needed  to 
establish  a  diagnosis. 

HypercestJietic  spine,  also  termed  the  hysterical  spine,  the  neuro- 
mimetic  spine,  is  characterized  by  tenderness  in  certain  portions 
of  the  back,  sometimes  accompanied  by  pain  or  ache.  This  condi- 
tion is  more  common  in  neurotic  persons,  but  may  be  seen  in 
others  who  have  been  suffering  from  nervous  exhaustion  from  any 
cause.  The  tenderness  may  be  intense  and  manifestly  exagger- 
ated, or  it  may  be  only  slight,  and  confined  to  small  spots  in  the 
lower  cervical  and  upper  dorsal  or  in  the  upper  lumbar  region. 
As  a  rule,  no  real  stiffness  in  the  back  is  present,  but  in  severe 
cases,  or  in  cases  which  have  remained  in  bed  for  some  time,  mus- 
cular stiffness  may  be  present.  This  condition  is  sometimes  seen 
after  railway  accidents.  In  the  cases  that  are  termed  "  railway 
spine,"  abnormal  projection  or  deformity  in  the  spine  does  not 
exist.  Referred  pains,  or  the  attitude  and  gait  characteristic  of 
Pott's  disease,  are  absent.  A  hyperaesthetic  spine  occurs  in  adults, 
and  especially  in  young  growing  girls ;  it  may  exceptionally  be 
seen  in  children. 

Malignant  disease  of  the  spine  presents,  when  a  projection  is 
found,  a  more  rounded  and  less  sharp  projection  than  is  seen  in^ 
the  beginning  of  caries.  Carcinoma  of  the  spine  is  usually  second- 
ary. The  symptoms,  however — pseudo-neuralgias,  paresis  and  par- 
alysis, .muscular  stiffness — are  the  same  in  both,  and  sometimes 
only  a  conjectural  diagnosis  can  be  made.  Carcinoma  never  occurs 
in  childhood,  and  primary  sarcoma  of  the  spine  in  childhood  must 
be  the  rarest  of  disorders. 

Much  the  same  may  be  said  of  the  curvatures  of  the  spine 
caused  by  aneurism,  except  that  the  diagnosis  is  usually  made  by 
auscultation  or  by  the  rational  symptoms  before  the  spine  is 
noticeably  affected. 

A  diagnosis  of  the  meningeal  tumors  within  the  spinal  canal 
would  necessarily  be  difficult;  the  symptoms  would,  however,  be 
nervous  symptoms  which  would  not  affect  the  gait  or  attitude, 
except  through  paralysis,  unless  the  pressure  of  the  tumor  should 
cause  absorption  of  the  vertebrae.  This  would  not  happen  until 
a  late  stage  of  the  affection,  and  a  recognition  of  the  affection 
would  be  made  easier  by  the  clinical  history. 

Besides  gummata  of  the  spinal  cord,  a  syphilitic  destruction  of 
the  spinal  vertebrae  is  among  the  medical  possibilities,  though  it  has 
hitherto  escaped  record.  If  it  were  limited  to  the  bodies  of  the 
vertebrae,  the  symptoms  would  in  every  way  resemble  those  of 
caries  of  the  spine;  the  clinical  history,  however,  and  the  age  of 
the  patient  might  serve  as  guides  to  an  idea  of  the  true  etiology. 


POTT'S  DISEASE.  47 

Sensitiveness  of  the  skin  over  the  spine,  or  pain  in  pressin^^  on 
the  spinous  processes  is  not  a  symptom  of  I'ott's  disease  and  it  is 
the  chief  feature  in  hypercesthesia.  Stiffness  and  constrained  at- 
titudes may  be  present,  but  of  course  angular  deformity  is  absent 
and  stiffness  is  variable  in  amount.  In  the  diagnosis  one  must 
depend  largely  upon  the  general  aspect  of  the  case,  the  presence 
of  ovarian  tenderness,  the  hysterical  "globus,"  and  the  other 
symptoms  of  that  ill-defined  condition,  hysteria. 

Rheumatoid  arthritis  (chronic  articular  rheumatism,  spondylitis 
deformans  of  the  spine)  is  an  affection  of  adult  life  characterized 
by  stiffness  and  some  arching  of  the  spine;  there  is  usually  little 
muscular  spasm,  and  no  unusual  projection  of  the  spinous  pro- 
cesses ;  in  some  instances  the  ribs  are  ankylosed  to  the  spine,  so 
that  no  expansion  of  the  chest  is  possible.  Patients  suffering  from 
this  affection  may  have  neuralgic  or  pseudo-neuralgic  pains  of  the 
nerves  issuing  from  the  spine  at  the  affected  part. 

With  regard  to  the  symptoms  of  sacro-iliac  disease,  perinephritis 
and  perityphlitis,  it  may  be  said  that  a  mistake  in  diagnosis  can 
happen  only  through  a  lack  of  acquaintance  with  the  symptoms  of 
these  affections.  It  should,  however,  be  borne  in  mind  that  in 
perityphlitis  and  in  perinephritis,  when  an  abscess  is  present,  a  con- 
traction of  the  thigh  may  occur  resembling  that  seen  in  psoas 
abscess.  The  absence  of  a  projection  or  irregularity  of  the  back, 
and  the  power  of  muscular  movement  of  the  back  in  these  cases, 
will  help  to  establish  the  fact  that  they  are  not  due  to  caries  of 
the  spine.     The  same  is  true  of  caries  of  the  sacrum. 

Prognosis. 

Pott's  disease  will  always  be  regarded  as  one  of  the  most  for- 
midable of  diseases;  its  long  course,  the  deformity  often  entailed, 
the  severity  of  the  complications  (abscess,  paralysis),  and  of  the 
symptoms  at  times;  and  the  occasional  termination  in  death, 
coming  only  after  years  of  suffering,  or  often  in  a  crippled  state, 
gfve  both  to  the  surgeon  and  to  the  non-professional  public  a  nat- 
ural dread  of  the  affection.  These  inferences  are,  however,  drawn 
from  the  severer  cases,  and  facts  show  that  the  disease  has  a  ten- 
dency to  spontaneous  recovery,  that  in  certain  parts  of  the  spine 
deformity  can  be  prevented,  and  that  in  few  affections  does  the 
Avork  of  the  surgeon  give  greater  relief  than  in  Pott's  disease. 

Mortality. — No  statistics  of  value  exist  as  to  the  percentage  of 
mortality  and  recovery.  Billroth  and  Menzel  report  23  deaths  in 
61  cases;  Jaffe  22  deaths  in  82  cases;  and  Mohr,  7  deaths  in  72 
cases.     In  a  disease  having  so  long  a  course,  a  number  of  patients 


48  ORTHOPEDIC  SURGERY. 

should  be  watched  for  a  long  number  of  years  in  order  to  obtain 
statistics  of  value.  The  percentage  of  mortality  would  be  greater 
in  adults  than  in  children.  In  a  certain  number  of  cases  spontane- 
ous recovery  has  taken  place  in  early  childhood.  Many  specimens, 
in  museums  also  exist,  which  show  complete  bony  union,  with 
entire  cessation  of  the  carious  process. 

Billroth  and  Menzel  found,  in  autopsies  of  702  cases,  tuberculo- 
sis of  other  parts  of  the  body  in  more  than  one-half  (fifty-six  per 
cent).  Amyloid  degeneration  was  found  in  fifteen  per  cent  of  the 
cases,  and  fatty  degeneration  of  the  kidney  in  twenty-two  per  cent. 
Mohr,  however,  found  the  latter  in  only  six  per  cent  of  the  cases, 
collected  by  him.  Mohr  found  tuberculosis  of  the  lungs  in  only 
eight  out  of  sixty-one  autopsies. 

Neidert  has  investigated  the  cause  of  death  in  patients  with, 
angular  deformities  of  the  spine,  the  result  of  Pott's  disease  which 
has  been  cured.  Patients  with  severe  deformities  die  of  heart 
fatigue  ordinarily,  patients  with  medium-sized  curvatures  die  often- 
est  of  phthisis,  and  die  young,  while  those  with  small  deformities- 
have  nearly  as  good  a  prospect  of  long  life  as  men  with  normal 
spines.  These  results  were  obtained  from  the  investigation  of 
thirty-one  specimens  in  the  Munich  Pathological  Institute.  The 
average  age  of  the  patients  at  the  time  of  death  was  forty-nine  and 
one-half  years.  Twenty-four  had  hypertrophy,  with  or  without 
dilatation,  of  the  right  side  of  the  heart,  four  had  muscular  degen- 
eration of  the  heart  walls,  and  two  had  stenosis  of  the  mitral  valve, 
one  showed  acute  miliary  tuberculosis,  eight  died  of  phthisis,  four 
of  pneumonia,  and  one  of  carbuncle.  ("  Causes  of  Death  in  Deform- 
ities of  Vertebral  Column,"  Inaugural  Dissertation,  Munich,  1886.) 

Lannelongue,  speaking  of  narrowing  of  the  aorta  in  Pott's  dis- 
ease, says  that  in  his  autopsies  he  has  noted  that  a  very  marked 
narrowing  of  the  calibre  of  the  aorta  was  not  uncommon.  In  one 
specimen  the  aorta  only  measured  sixteen  millimetres  before  the 
origin  of  the  brachio-cephalic  trunk;  twelve  millimetres  after  the 
carotids  had  been  given  off,  and  only  eight  millimetres  in  the 
region  of  the  second  lumbar  vertebra.  In  another  specimen  the 
lumen  of  the  aorta  was  reduced  to  a  mere  slit.  These  changes  are 
consequent  upon  the  abnormal  curves  given  to  the  vessels,  and 
their  existence  explains  the  production  of  certain  rapid  and  pecu- 
liar paralyses  which  come  on  in  spinal  caries  and  which  are  not 
due  to  compression  of  the  cord. 

Cause  of  Death. — Michel  gives  as  causes  of  death  in  44  cases  of 
spinal  abscess:  in  14,  tuberculosis  of  lungs;  in  16,  marasmus;  in  5, 
sloughing  of  limbs  from  oedema;  in  4,  pyaemia;  in  2,  arachnitis;, 
in  2,  pus  in  the  medullary  canal;  and  in  i,  pneumonia. 


POTTS.   DISEASE.  49 

Mohr,  in  9  cases  of  fatal  abscess,  found  perforation  into  the 
•oesophagus  in  2  ;  pleura  and  lungs  in  2  ;  pleura  alone  in  i  ;  i^eri- 
toneum  in  i  ;  spinal  canal  in  2. 

Perforation  into  a  large  artery  has  been  noted. 

Death  has  occurred  from  the  rupture  of  a  spinal  abscess,  which 
discharges  into  the  bronchi. 

Abscess. — The  frequency  of  the  complication  of  an  abscess  varies 
somewhat  according  to  the  locality  of  the  disease;  this  is  most 
common  in  the  lumbar,  and  least  common  in  the  cervical,  region. 

Mohr  found,  in  61  cases  at  autopsy,  thirty  abscesses.  Of  these 
but  one  was  of  cervical  caries;  and  the  number  of  lumbar  cases 
with  abscess  was  twice  that  of  dorsal.  In  life,  abscess  existed  in 
but  9  of  72  cases. 

Cases  of  recovery  after  rupture  or. evacuation  of  abscess  are  not 
;SO  rare  as  to  be  exceptional,  but  abscesses  in  adults  must  be  looked 
upon  as  much  more  unfavorable  as  to  prognosis  than  in  children. 
The  prognosis  will  depend  largely  upon  the  situation  of  the 
abscess,  the  completeness  of  evacuation,  and  the  amount  of  drain- 
age possible. 

The  occurrence  of  psoas  abscess  and  contraction  of  the  thighs 
will  add  much  to  the  difificulty  and  the  length  of  treatment.  Ab- 
scess in  itself  does  not  make  the  prognosis  much  more  grave,  al- 
though, as  a  rule,  abscesses  characterize  severer  grades  of  cases. 
The  discharge  is  likely  to  be  prolonged  and  exhausting,  and  the 
sinuses  are  likely  to  continue  open  for  a  long  time,  perhaps  for 
months  and  years. 

Age. — The  prognosis  in  the  case  of  adult?  is  not  nearl}'  so  favor- 
able as  in  the  case  of  children,  and  it  should  be  very  guarded  both 
as  to  ultimate  recovery  and  the  permanent  benefit  to  be  derived 
from  treatment.  Phthisis  is  much  more  likely  to  develop  than  in 
children  and  the  local  process  seems  to  possess  an  activity  greater 
than  in  young  children. 

Deformity. — The  tendency  of  the  deformity  is  to  increase,  and 
this  is  especially  marked  in  the  upper  dorsal  region ;  instances  of 
arrest  without  marked  deformity  are  not  so  very  rare  in  upper 
cervical  disease,  and  in  lower  dorsal  disease;  but  in  the  upper  and 
middle  dorsal  regions  the  tendency  is  for  an  increase  of  the  de- 
formity proportionate  to  the  extent  of  the  disease. 

It  has  been  frequently  stated  that  a  recession  of  the  deformity 
does  not  take  place.  Such  instances  are  rare,  but  have  been  ob- 
served. The  lost  parts  of  the  vertebral  column  are  not  regained, 
but  growth  takes  place  in  the  normal  vertebra  and  is  arrested  in 
the  ankylosed  vertebree;  the  projection  is  then  proportionately 
less,  and  practically  less  prominent.  As  a  rule,  however,  the  pro- 
4 


50 


ORTHOPEDIC  SURGERY. 


jection  increases  somewhat  during  the  growing  years,  and  with  it 
there  is  necessarily  an  increase  in  the  compensatory  curves. 

In  some  cases,  an  arrest  of  the  growth  of  the  whole  child  takes 
place  apart ,  from  the  loss  of  vertebral  substance.  A  peculiarity 
in  the  shape  of  the  jaw  and  face  is  also  observed  in  cervical  and 
upper  dorsal  caries. 

Prognosis  as  to  Time  in  Recovery. — No  reliable  statistics  exist  as 
to  the  amount  of  time  necessary  to  establish  a  cure  in  Pott's  dis- 
ease. The  disease  varies  greatly  as  to  its  self-limitation  in  individ- 
uals, and   according  to   the   situation   and    extent   of  the   disease. 

Necessarily  there  will  be  a  difference  in  individual  cases  in  the 
result  of  treatment. 

Relief  from  symptoms  is  often  easily  obtained,  but  to  establish  a 
complete  cure,  so  that  there  be  no  latent  disease,  requires  protec- 
tion and  treatment  for  years. 

It  may  be  said  that,  as  the  bodies  in  the  cervical  region  are 
smaller  than  those  in  the  lumbar,  the  time  required  for  self-limita- 
tion here  is  shorter  than  in  the  lumbar  region.  In  the  latter  region,, 
also,  the  superincumbent  weight  is  a  more  important  factor  than 
in  the  upper  part  of  the  spine. 

Roughly  speaking  it  is  always  possible  to  predict  a  course  of 
treatment  which  shall  last  not  less  than  three  years  and  probably 
longer.  Until  one  has  seen  the  frequency  with  which  relapses 
occur  in  cases  which  are  apparently  cured,  when  treatment  has 
been  discontinued  too  early,  it  is  impossible  to  appreciate  the  true 
danger  in  an  early  discontinuance  of  treatment. 

The  occurrence  of  bony  ankylosis  firm  enough  to  support  the 
column  in  its  weight -bearing  function  must  be  a  process  requiring 
a  long  time  for  its  completion,  to  judge  from  it  as  observed  else- 
where; and  nowhere  is  protection  more  urgently  demanded  during 
convalescence  than  in  the  vertebral  column.  This  is  especially 
true  in  growing  children.  Cases  of  supposed  cure  of  caries  of  the 
spine  have  re-developed  symptoms  of  caries  at  the  period  of  rapid 
growth  at  the  approach  of  puberty.  It  should  especially  be  borne 
in  mind  that  protection  to  the  spine  may  be  needed  at  this  period. 

Paralysis  in  Pott's  disease  shows  a  remarkable  tendency  to  re- 
cover, as  has  been  already  stated — a  fact  that  many  authorities 
have  overlooked,  taking  their  statistics  from  incurable  hospital 
cases. 

The  cases  investigated  by  Taylor  and  Lovett  gave  the  following 
results : 

Of  the  59  cases  analyzed,  39  wholly  recovered,  3  recovered  in 
part,  5  died  of  intercurrent  affections,  and  in  12  cases  the  termina- 
tion is  unknown.     That  is  to  say,  in  the  whole  number  of  cases 


POTTS  DISEASE,  5 1 

where  the  termination  was  known,  cit^iity-thrcc  per  cent  recovered 
wholly  from  the  paralysis;  and  this  percentage  is  undoubtedly  too 
low,  for,  of  the  cases  which  died,  2  were  recovering  and  2  others 
were  probably  over  their  paralysis  when  they  died,  although  they 
cannot  be  so  counted.  Of  the  deaths,  2  were  due  to  pneumonia,  i 
to  acute  phthisis,  i  to  the  opium  habit,  and  i  to  acute  cerebral 
meningitis.  The  termination  was  unknown  in  so  many  cases  because 
they  came  only  for  consultation,  or  disappeared  from  observation 
after  a  little  while,  or  were  discharged  for  neglect.  The  bladder 
and  rectum  are  noted  as  having  been  paralyzed  in  8  cases,  and  here 
the  per  cent  of  recoveries  fell  to  fifty-seven,  in  the  cases  in  which 
the  result  was  known.  The  arms  were  affected  in  3  cases.  Of 
these,  I  recovered  wholly  and  the  other  2  partly.  Muscular  rigid- 
ity is  noted  in  5  cases,  of  which  2  recovered  wholly,  but  it  was  un- 
doubtedly present  in  many  others.  The  latter  symptoms  mean 
much  damage  to  the  cord,  and  the  wonder  is  that  any  recover 
from  them.  Where  the  paralysis  came  on  while  the  patient  was 
under  treatment  (19  cases),  the  percentage  of  recoveries  was  one 
hundred  in  the  17  cases  whose  termination  Avas  known.  Of  the  2 
cases  where  the  termination  was  doubtful,  i  was  recovering  power 
quite  fast  at  the  end  of  six  months,  and  the  other  was  still  para- 
lyzed when  two  years  had  gone  by.  Neither  has  been  heard  from 
since. 

The  average  duration  of  all  these  cases  was  a  little  less  than  one 
5^ear.  When  the  paralysis  came  on  under  treatment,  the  average 
duration  was  only  seven  months.  The  disappearance  of  the  paral- 
ysis wa3  gradual — the  sensory  part  recovered  first,  then  the  motor, 
and  last  of  all  the  tendon  reflexes  became  normal.  In  three  or 
four  cases  the  recovery  followed  in  a  few  days  or  weeks  after  the 
evacuation  of  an  abscess,  and  in  one  case  the  recovery  was  sudden 
and  occurred  during  an  attack  of  measles,  after  the  paralysis  had 
lasted  two  years.  A  recurrence  of  the  paralysis  was  not  uncom- 
mon, having  occurred  in  6  cases— 4  patients  had  two  attacks,  and  2 
others  had  three.  The  intervals  between  these  recurrences  varied 
from  a  few  weeks  to  some  years. 

Recovery  may  take  place  after  complete  motor  paraplegia  with 
marked  sensory  impairment.  In  a  few  cases  the  paralysis  recurs. 
Treves  quotes  a  case  of  recovery  after  complete  paralysis  of  the 
lower  limbs,  with  loss  of  power  of  the  upper  extremities  and  in  the 
bladder.  He  mentions  a  case  of  two  attacks  of  paralysis,  occur- 
ring in  the  same  patient  in  two  years,  which  were  followed  by  re- 
covery; and  another  of  three  attacks  of  paralysis  in  eight  years,  in 
a  man  of  twenty-four. 

The  presence  of  marked  paralysis  of  sensation  indicates  an  ex- 


52  ORTHOPEDIC  SURGERY. 

tensive  myelitis  involving  the  posterior  as  well  as  the  anterior 
columns  of  the  cord.  Some  impairmenf  in  sensation  is  found  in 
all  cases  of  paralysis  in  Pott's  disease,  but  it  is  usually  so  slight  as 
only  to  be  "recognized  by  the  most  delicate  tests  and  for  a  short 
time.  Paralysis  of  sensation  may  be  complete  and  yet  recovery 
result,  as  in  a  case  in  the  experience  of  the  writers  where  the  loss 
of  sensation  was  so  great  that  a  bandage  was  accidentally  pinned 
to  the  skin,  without  pain  to  the  patient.  Complete  recovery  from 
paralysis  of  sensation  and  motion,  however,  occurred  in  a  year. 
But  paralysis  of  sensation,  especially  if  combined  with  paralysis  of 
the  rectum  and  bladder,  makes  the  prognosis  less  favorable. 

Prognosis  is  necessarily  made  much  less  favorable  by  the  exist- 
ence of  amyloid  disease  of  the  viscera,  which  frequently  follows 
long-continued  suppuration. 

Although  the  prognosis  in  Pott's  disease  is,  as  in  all  diseases,  in 
a  measure  uncertain,  it  is  possible  to  promise  almost  certain  im- 
provement from  proper  and  careful  treatment,  and  in  many  cases 
to  anticipate  ultimate  cure.  The  final  course  of  the  disease  must 
in  many  cases  remain  uncertain,  but  it  is  the  experience  of  the 
writers  that  the  uncertainties  of  prognosis  are  no  greater  in  this 
than  in  other  grave  chronic  disorders.  Instances  of  spontaneous . 
complete  recovery  from  well-advanced  Pott's  disease  have  been 
undoubted. 

The  prognosis  of  average  cases  coming  under  thorough  treat- 
ment is  by  no  means  unfavorable.  But  treatment  must  be  thor- 
ough and  long  continued  in  all  cases  of  any  severity.  The  prog- 
nosis in  adult  cases  is  necessarily  much  more  unfavorable  than  in 
children. 

Treatment  of  Pott's  Disease. 

After  considering  the  pathological  appearances  of  a  disease  which 
is  at  times  as  severe  as  Pott's  disease,  it  is  natural  that  the  surgeon 
reading  the  recorded  facts  should  be  appalled  at  the  formidable 
complications  and  alarming  terminations  which  are  possible.  But 
extended  experience  will  give  a  much  more  favorable  view  of  the 
matter.  The  course  of  Pott's  disease  is  necessarily  a  long  one  and 
the  treatment  should  be  continued  through  many  years,  but  in  few 
affections  can  results  more  satisfactory  to  the  surgeon  be  gained 
than  in  the  treatment  of  this  affection,  for  these  results  are  gained 
only  by  thorough  treatment  and  the  exercise  of  good  sense  and 
judgment.  Whether  the  surgeon  shall  use  the  methods  of  recum- 
bency, whether  he  shall  employ  braces,  or  corsets,  and  whether  he 
shall  interfere  surgically  must  depend  not  only  upon  the  surgical 
conditions  of  the  case,  but  also  upon  the  surroundings  of  the  patient. 


POTT'S   J) /S /CASE. 


53 


He  will  be  able  in  all  cases  to  alleviate  pain,  and  in  a  majority 
of  cases  to  effect  a  cure,  and  this  cure  will  result  with  or  without  a 
deformity  according  to  extent  of  disease,  its  situation,  anrl  also 
according  to  the  thoroughness  of  treatment  and  the  care  and  nurs- 
ing given  to  the  patient.  In  a  large  number  of  instances  the  cure 
is  permanent  and  the  patients  are  able  to  carry  on  active  occupa- 
tions throughout  life.  Cases  of  cervical  caries  are  usually  treated 
with  the  greatest  satisfaction,  as  their  course  is  shorter.  The 
symptoms,  however,  at  times  may  be  alarm- 
ing and  the  pain  may  be  great. 

Cases  of  the  upper  dorsal  region  are  the 
most  difificult  of  treatment,  as  the  preven- 
tion of  deformity  requires  much  thorough- 
ness of  treatment  and  in  some  cases  this 
is  impossible.  Patients  with  disease  in  the 
Jower  dorsal  region  are  treated  with  great 
satisfaction. 

The  accompanying  picture  will  illustrate 
the  results  Avhich  may  be  obtained  in  severe 
cases  if  persistently  treated.  It  is  that  of 
a  boy  of  the  age  of  eleven  who  five  years 
before  presented  a  sharp  angular  curvature 
in  the  lower  dorsal  region.  A  large  ab- 
dominal abscess  was  formed  on  the  left 
side,  which  was  opened  by  incisions  in  the 
groin  and  back.  The  patient  was  fixed  in 
a  recumbent  position  and  remained  so  for 
nine  months.  A  second  abscess  formed 
on  the  right  side,  which  was  also  incised, 
the  sinuses  discharged  for  two  years.  At 
the  end  of  seven  months  the  patient  was 
fitted  with  an  antero-posterior  support  and  was  allowed  to  go  about 
using  crutches.  These  latter  were  discarded  at  the  end  of  a  year 
and  at  the  present  time  the  boy  is  to  all  appearances  well,  is  as 
well  able  to  play  as  other  children  and  enjoys  perfect  health. 

It  cannot  be  claimed  that  results  of  this  kind  can  be  gained  in 
every  case,  but  this  case  represents  a  class  Avhich  is  by  no  means 
uncommon,  and  such  results  can  be  fairly  anticipated  where  good 
nursing  and  persistent  treatment  are  possible. 

Principles  of  Treatment. — The  principles  of  treatment  of  caries  of 
the  spine  are  simple,  though  their  practical  application  is  attended 
with  difficulty. 

The  diseased  vertebral  bodies  should  be  protected  from  jar  and 
pressure   until   a   cure   is   accomplished.     As   in   ostitis   elsewhere, 


Fig.  6o. — Result  in  a  Severe  Case 
of  Dorsal  Pott's  Disease. 


54  ORTHOPEDIC  SURGERY. 

there  is  always  an  effort  toward  repair,  and  everything  should  be 
avoided  which  would  hinder  this  reparative  process.  The  jars 
which  come  upon  the  spinal  column  are  chiefly  those  received  in 
bending  the  column  forward,  and  pressure  upon  the  vertebral 
bodies  comes  from  the  superincumbent  weight  of  the  head  and 
trunk.  In  treating  a  diseased  vertebra,  therefore,  the  superim- 
posed weight  should  be  removed  from  the  part  affected,  so  far  as 
is  practicable,  and  all  bending  forward  avoided,  the  spinal  column 
being  fixed  so  as  to  secure  rest  for  the  vertebral  bodies. 

Furthermore,  as  the  inevitable  tendency  of  the  spinal  column, 
weakened  in  front,  would  be  to  fall  forward,  deformity  will  take 
place  if  the  vertebral  column  is  left  unsupported,  and  in  treatment 
every  effort  should  be  made  to  limit  the  increase  of  that  deformity, 
or  if  possible  to  prevent  it. 

It  will  be  readily  understood  that  thorough  treatment  of  caries 
of  the  spine  involves  much  time,  partly  because  the  disease  is 
rarely  discovered  until  much  progress  has  been  made,  and  partly" 
also  because  the  reparative  process  in  bones  of  the  size  and  situa- 
tion of  the  vertebral  bodies  is  necessarily  slow.  A  cure  cannot  be 
considered  as  having  taken  place,  in  a  structure  which  has  to  bear 
so  much  weight  as  the  spine,  until  it  is  able  to  sustain,  without 
injury,  any  jar  which  may  come  upon  it;  otherwise  a  relapse 
is  apt  to  occur.  It  is  because  so  much  time  is  required  that 
surgeons  are  sometimes  obliged  to  be  satisfied  with  what  must 
be  considered  imperfect  results.  Given  perfect  conditions,  it  is 
theoretically  as  possible  to  bring  about  a  cure  without,  as  it  is  with, 
an  increase  of  deformity,  provided  a  cure  can  be  effected  at  all. 
Practically,  it  is  difficult  to  secure  the  requisite  conditions  of  com- 
plete fixation  and  ideal  position,  and  perfect  results  are  rarely 
attained ;  but  it  has  been  shown,  by  reliable  clinical  evidence,  that 
prevention  and  recession  of  the  deformity  are  sometimes  won  ;  that 
prevention  of  increase  of  the  curve  and  cure  may  in  many  cases  be 
expected  to  follow  thorough  treatment ;  and  that  relief  and  benefit 
are  always  to  be  looked  forward  to  as  a  reward  for  careful  treat- 
ment. 

Methods  of  Treatment. — The  methods  which  have  been  used  to 
remove  from  the  spine  the  superimposed  weight  are,  first,  recum- 
bency, and,  second,  suspension  and  fixative  appliances,  such  as 
braces  and  corsets.  They  constitute  the  methods  of  treatment, 
and  have  respectively  certain  advantages  and  disadvantages  which 
should  be  clearly  understood  by  the  surgeon. 

Treatment  by  Recumbency. — If  the  patient  lies  upon  his  back,  or 
upon  his  face,  on  a  hard  surface,  there  is  no  superincumbent 
weight  pressing  upon  any  portion  of  the  spine.     If  the  patient  lies 


POTT'S  DrSEASIC. 


55 


upon  his  back  upon  a  spring-bed,  and  the  bed  sags,  the  spine  is,  of 
course,  bent,  and  pressure  upon  the  vertebrae,  proportional  in 
amount  to  the  extent  of  the  curve,  results.  This  can  readily  be 
demonstrated  by  measuring  the  length  (jf  a  person  lying  flat,  and 
comparing  it  with  his  height  as  he  stands.  It  will  be  found  that 
there  is  an  increase  while  the  person  is  recumbent,  of  from  one  to 
one  and  a  half  inches,  due  to  the  obliteration  of  the  curves  of  the 
spine.  If  a  small  pillow  is  placed  under  the  back  so  that  it  is 
curved  with  the  convexity  forward,  the  bodies  are  separated  in 
proportion  to  the  amount  of  the  curve. 

In  thorough  treatment  by  recumbency  it  is  not  suf^cient  that 
the  patient  be  placed  in  bed;  he  should  not  be  permitted  to  sit 
up,  lie  upon  one  side  (twisting  the  spine),  or  bend  forward  while  on 
his  side.     The  patient,  however,  can  lie  upon  his  face. 

The  patient,  if  unruly  or  restless  at  night,  can  be  prevented  from 
sitting  up  by  pinning  the  shoulders  of  the  night-dress  to  a  sheet 
which  Ts  secured  to  the  sides  of  the  bed ;  or,  better,  by  straps  in 
the  following  way:  A  soft  cloth  strap  is  placed  across  the  bed  at 
the  height  of  the  patient's  shoulders,  and  secured  at  the  sides;  it 
is  also  prevented  from  moving  down  by  a  cross-strap  secured  at 
the  top  of  the  bed;  if  the  patient's  shoulders  are  secured  to  the 
straps  by  loops  around  the  axillae  (these  loops  being  fastened  to 
the  straps),  the  patient  can  neither  sit  up  nor  roll  to  one  or  the 
other  side  to  any  extent.  A  belt  about  the  hips,  secured  by  side- 
straps  to  the  sides  of  the  bed,  will  prevent  the  pelvis  from  moving 
sideways,  and  the  patient  is  thus  held  suf^ciently  secure.  Sand- 
bags placed  at  the  sides  of  the  patient  also  aid  in  preventing  side 
movements.  An  excellent  means  of  retention  has  been  described 
by  Fisher  {^Lancet,  February,  1878.) 

The  bed  should  be  flat,  and  the  patient  should  use  no  pillows. 

This  way  of  securing  the  patient,  however,  does  not  enable  him 
to  be  lifted  or  moved  readily,  and  is  objectionable  on  that  account. 
In  children  this  can  be  obviated  by  arranging  a  bed-frame  in  the 
following  way : 

If  four  stout  steel  bars,  one-half  inch  wide  and  one-fourth  in 
thickness,  be  fastened  together  so  as  to  make  an  oblong  frame  of 
the  patient's  height  and  width,  and  over  this  stout  sheeting  be 
wound  and  fastened,  the  patient  can  lie  on  this,  if  it  be  placed 
upon  the  bed,  as  comfortably  as  upon  the  bed;  straps  across  the 
shoulders,  fastened  to  buckles  secured  to  the  frame,  and  others 
about  the  hips,  will  secure  the  patient  in  a  recumbent  position, 
while  the  frame  and  child  can  be  lifted  and  carried  about  easily. 
The  sheeting  can  be  readily  changed  when  soiled ;  no  padding  is 
needed.     The  sheeting  should  be  cut  out  at  the  reeion  of  the  but- 


56  ORTHOPEDIC  SURGERY. 

tock,  so  that  the  bed-pan  can  be  used.  Traction  of  the  spine  can 
be  employed  by  attaching  an  arm  at  the  head  of  the  frame  to 
secure  the  sling.  This  arrangement  is  more  comfortable  and  much 
cheaper  than  a  Bonnet's  wire  cuirass,  and  can  be  made  as  efficient 
in  fixing  the  spine.  The  same  can  be  used  in  older  persons,  but 
it  requires  a  stouter  frame,  and  there  is  more  diflficulty  in  lifting 
the  patient.  One  of  the  chief  advantages  of  this  apparatus  is  the 
ease  with  which  the  patient  can  be  carried  about  and  be  taken  out 
of  doors,  thus  avoiding  the  evils  of  long  indoor  confinement. 

Traction,  so  much  used  by  the  earlier  French  orthopedists,  can 
hardly  be  thought  to  separate  directly  the  diseased  vertebrae,  as 
was  originally  supposed,  except  when  applied  in  the  cervical 
region.  Experiment  has  shown  that  great  force  is  required  to  pulL 
the  normal  vertebrse  apart.  Traction,  or  extending  weights  ap- 
plied to  the  trunk,  may,  however,  diminish  the  physiological  curves, 
and  thus  diminish  pressure.  This  extending  force  is  readily  ap- 
plied by  means  of  belts  about  the  pelvis  and  thorax.  These  belts 
are  supplied  with  straps  and  cords,  which  pass  to  the  foot  and  head. 


Fig.  6i. — Frame  to  Secure  Recumbency  and  Fixation,  and  to  Allow  Patient  to  be  Moved  About. 

of  the  bed  respectively,  and  running  over  pulleys,  exert  force  by 
means  of  attached  weights.  In  some  acute  cases  this  system 
affords  relief,  probably  as  a  correction  of  muscular  spasm,  and  also 
as  a  means  of  fixing  the  patient,  and  possibly,  in  directly  diminish- 
ing inter-vertebral  pressure. 

The  pressure  of  the  adjacent  vertebrae  can  be  diminished  by 
pads  placed  under  the  body,  pressing  the  spine  forward.  They 
should  be  thick  enough  not  to  flatten  to  such  an  extent  as  to  be 
inefficient,  and  soft  enough  to  be  comfortable.  It  will  be  found 
that  curled  hair  or  the  best  of  felt  will  meet  the  requirement ;  they 
should  be  so  arranged  that,  as  the  patient  lies  on  his  back,  the 
pressure  should  come  over  the  sides  of  the  vertebrae,  and  not  upon 
the  spinous  processess. 

In  disease  of  the  cervical  region  traction  will  be  found  of  great 
assistance  in  acute  cases,  the  relief  afforded  being  often  very 
marked.  It  is  obtained  by  securing  the  head  in  a  sling,  similar  to 
that  used  for  suspension,  which  passes  under  the  chin  and  occiput; 
to  this  is  attached  a  cord  which  runs  over  a  pulley,  and  is  supplied 
with  a  light  weight  (one-half  to  one  pound).     Counter-extension  is 


POTT'S  J)  IS  EASE. 


57 


supplied  by  the  weight  of  the  patient's  body,  if  the  head  of  the  bed 
is  raised. 

Traction  in  the  lumbar  region  may  also  be  applied  by  employing 
extension  by  weight  and  pulley  (as  in  I^uck's  extension  for  frac- 
tured thigh)  to  both  legs,  and  raising  the  foot  of  the  bed. 

Treatment  by  recumbency  will  be  found  of  service,  either  alone 
or  in  conjunction  with  other  methods,  in  cases  with  acute  symp- 
toms, in  cases  of  severe  cervical  caries,  and  in  caries  of  the  lower 
lumbar  region.  In  children  the  irksomeness  of  the  confinement 
passes  off  readily;  but  in  adults  the  imprisonment  constitutes  a 
serious  obstacle  to  the  employment  of  the  method. 

Patients  who  have  been  suffering  will  often  be  found  to  gain  flesh 
after  the  relief  afforded  by  recumbency,  though  the  muscles  in  the 
limbs  diminish  in  size.  Treatment  by. recumbency,  if  used,  should 
be  thorough.  Half  measures  have  the  evils  of  the  imprisonment 
without  the  benefit  of  fixation.  The  limit  of  its  usefulness  is 
usually  marked  by  the  restlessness  of  the  patient. 

The  objections  to  treatment  by  recumbency  are  evident.  Pott's 
disease  is  a  tubercular  affection  and  close  confinement  is  injurious 
to  patients  with  a  tubercular  taint.  Patients  of  this  sort  need  all 
possible  help  from  fresh  air  and  exercise,  and  the  method  of  treat- 
ment by  recumbency  for  years,  formerly  the  only  thorough  method 
possible,  is  not  now  regarded  as  necessary  in  all  cases. 

It  is  impossible  to  define  precisely  in  what  cases  or  at  what  stage 
recumbency  is  needed.  In  the  acute  stages  recumbency  is  abso- 
lutely necessary,  and  where  paralysis  or  abscess  is  threatened,  re- 
cumbency for  a  few  months  will  bring  about  more  favorable  symp- 
toms. In  cases  causing  much  anxiety,  recumbency  should  for  a 
while  form  an  essential  part  of  the  treatment.  In  cases  needing 
this  treatment  it  will  be  found  that  the  patients  begin  to  improve 
in  appetite,  flesh,  and  general  condition  after  a  week's  recumbency. 
If  recumbency  is  continued  for  too  long  a  period,  the  patient's 
condition  ceases  to  improve  and  the  tonic  of  improved  circulation 
and  activity  is  required.  After  some  experience  a  surgeon  Avill 
learn  to  estimate  for  what  cases  recumbency  is  most  advisable.  It 
may  in  general  be  stated  that  such  patients  as  become  easily  tired 
when  on  their  feet  and  those  who,  though  well-supported  mechan- 
ically, frequently  desire  to  lie  down,  will  improve  if  all  weight  can 
be  taken  from  the  spinal  column.  This  can  be  most  thoroughly 
done  in  a  recumbent  position,  with  thorough  mechanical  support, 
and  with  suspension  appliances,  or,  in  dorsal  and  lumbar  caries, 
patients  who  are  recumbent  for  a  greater  part  of  the  time  may  be 
allowed  some  activity  with  the  aid  of  crutches,  for  a  short  time 
each  day.     The  amount  of  time  should  be  increased  as  the  patient 


58  •  ORTHOPEDIC  SURGERY. 

improves,  with  the  use  of  the  frame  or  with  the  "  gouttiere  "  (to  be 
described  under  the  treatment  of  hip  disease)  patients  (if  children) 
can  be  moved  about  readily  and  given  the  benefit  of  fresh  air. 

A  combination  of  the  treatment  of  recumbency  and  mechanical 
fixation  will  be  of  advantage  in  the  severer  cases,  and  at  times 
relief  from  pain  may  be  afforded  by  recumbency  combined  with  a 
light  weight  attached  to  each  leg  by  a  plaster  extension,  by  allow- 
ing the  body  to  act  as  a  counter-extending  force  mild  traction  is 
exerted  upon  the  diseased  part  of  the  vertebral  column  which 
exerts  a  sedative  effect  upon  the  irritated  muscles. 

It  has  semed  to  the  writers  that  in  this  as  in  other  forms  of 
tuberculous  joint  disease  the  tendency  to  tuberculous  meningitis  is 
favored  by  too  prolonged  or  ill-judged  confinement  in  bed. 

In  cases  convalescent  from  paralysis  and  in  another  class  of 
cases  where  the  general  prostration  is  extreme,  exercise  may  be  ob- 
tained by  the  use  of  one  of  the  appliances  shown  in  Figs.  62  and  63. 

Treat-ment  by  Suspension. — The  pressure  upon  the  diseased  verte- 
brae by  superimposed  weight  can  be  removed  by  suspension. 

Suspending  a  healthy  person  by  the  head  obliterates  the  physi- 
ological curves  (cervical  and  lumbar  lordosis,  dorsal  kyphosis),  and 
the  spine  becomes  straight  so  far  as  its  formation  will  allow.  The 
spine  of  a  new-born  child  becomes  straight  by  suspension,  but  in 
an  adult  the  changes  in  the  shape  of  the  bones  and  the  strength  of 
ligaments,  and  the  tension  of  the  muscles,  prevent  the  spinal 
column  from  becoming  perfectly  straight. 

In  suspension  by  the  axillae  or  arms  the  strain  comes  upon  the 
latissimus  dorsi  muscles,  and  though  the  superimposed  weight 
which  would  fall  upon  the  lower  part  of  the  spinal  column  is  re- 
moved, yet  the  curvatures  in  the  upper  part  of  the  spine  are  not 
made  straight. 

In  suspension,  in  old  caries  of  the  spine,  it  is  only  the  physiologi- 
cal curves  which  are  obliterated ;  the  sharp  kyphosis  is  held  too 
firmly  by  inflammatory  adhesions  to  permit  of  correction;  in 
earlier  cases  with  movable  vertebrae,  the  intra-vertebral  pressure 
must  be,  in  a  measure,  diminished  at  the  point  of  disease  by  sus- 
pension, but  suspension  does  not  cause  a  disappearance  of  the 
sharp  angular  projections  at  the  point  of  disease,  and  in  cases  that 
present  themselves  for  treatment  the  deformity  cannot  be  cor- 
rected in  that  way. 

Complete  suspension  as  a  remedial  agent  can  necessarily  be  used 
only  temporarily,  in  holding  the  trunk  in  a  better  position  while 
corsets  and  appliances  are  fixed  to  the  spine.  Partial  suspension 
is  also  used,  applied  by  means  of  chairs  and  wheel-carts,  or  by  a 
sliding  pulley  attached  to  a  bar  in  the  ceiling,  enabling  the  patient 


POTT'S   DISEASE 


59 


to  sit  up  and  walk  about  without  allowing  the   full  superimposed 
weight  of  all  on  the  spine.     In  patients  suffering  with  the  symp- 


FiGS.  62  and  63. — Appliaaces  Allowing  Locomotion  and  Relieving  Superincumbent  Weight. 


G 

Fig.  64.— Jury-mast  before  Incorporation. 


Fig.  65. — The  Jur>--mast  Applied. 


toms  of  Pott's  disease,  relief  will  be  afforded  by  suspension  without 
causing  much  discomfort  by  the  pressure  of  straps  on  the  head  and 


6o 


ORTHOPEDIC  SURGERY, 


neck.     The  amount  of  time  that  complete  suspension  can  be  used 
varies  with  the  size  and  weight  of  patients. 

Suspension  will  be  found  to  be  more  ef^cient  in  disease  of  the 
cervical  and  upper  and  middle  dorsal  regions  than  in  that  of  the 
lower  part  of  the  spine,  for  the  higher  the  disease  the  less  is  the 
superimposed  weight,  and  the  less  the  difficulty  met  with  in  apply- 
ing to  the  head  an  efficient  suspending  force. 

The  only  practical  application  of  continued  suspension  in  the 
treatment  of  Pott's  disease  is  found  in  caries  of  the  cervical  region, 

when  suspension  can  really  be 
obtained  by  a  jury-mast  running 
up  from  a  plaster  jacket  as  a 
base,  in  the  manner  soon  to  be 
described.  Traction  may  be  ex- 
erted by  the  elasticity  of  the 
bent  iron  rod  forming  the  up- 
ward continuation  of  the  jury- 
mast. 

A  simple  appliance  for  a  head 
rest  with  the  plaster  jacket  is 
shown  in  the  simple  bent-wire 
head  piece  by  which  extension 
may  be  obtained.  The  head  rest 
opens  at  the  back  and  when  the 
head  is  in  place  buckles  behind 
the  neck.  The  lower  part  of  the 
head  piece  runs  down  on  to  the 
chest  and  buckles  by  webbing 
on  to  the  upper  part  of  the 
jacket,  so  that  by  tightening  the 
straps  the  whole  head  piece  may 
be  raised  (Fig.  G"]^. 
A  most  thorough  and  exhaustive  investigation  of  the  effect  of 
suspension  in  caries  of  the  spine  has  been  published  by  Anders 
{ArcJiiv  f.  klinische  Chiriirgie,  1889,  38  Bd.,  3d,  p.  558).  His  con- 
clusions coincide  with  those  of  previous  investigators,  but  his  re- 
searches are  more  thorough  than  have  previously  been  reported. 
He  proves  conclusively  that  the  effect  of  suspension  in  caries  of 
the  spine  is  not  to  separate  the  diseased  vertebrae,  or  in  fact  to 
directly  affect  the  projection.  The  flexible  portion  of  the  spine  is 
altered  by  suspension,  as  it  can  also  be  altered  by  recumbency, 
the  prone  position,  or  different  attitudes 

The  undoubted  beneficial  effect  of  plaster  jackets  is  due,  not  to 
the  separation  of  the  affected  vertebrae,  but  to  a  fixation  support 


Fig.  66.- 


■  Sayre  Head-piece  for  Suspension  in  Pott's 
Disease. 


POTTS  J)ISEASE. 


6i 


in  an  improved  position.     In  short  that  pLastcr  jackets  afford  an 
excellent  antero-posterior  support. 

Treatment  by  Means  of  Fixative  Appliances. — The  irksomeness  of 
the  method  of  treatment  by  recumbency,  and  the  practical  impos- 
sibility of  carrying  Out  thorough  treatment  in  a  large  number  of 
cases  during  the  whole  period  of  time  necessary  for  complete  cure 
(i.e.,  until  the  spine  has  been  restored  to  its  ability  to  bear  weight 
without   likelihood   of   relapse),   has   always   justified    attempts    to 


Fig.  67. — Plaster  Jacket  with  Bent-wire  Head  Piece. 


Fig.  68. — Jury-mast  and 
Plaster  Jacket. 


secure  fixation  of  the  spine,  permitting  locomotion.  From  the 
days  of  Ambroise  Fare's  hammered  brass  cuirass  to  that  of  the 
plaster  jacket,  the  corset  has  been  a  favorite  form  ;  but  crutches, 
springs,  and  steel  supports  have  been  employed  in  a  great  variety 
of  ways. 

The  tests  of  an  appliance  are  its  efficiency,  its  convenient  use, 
and  the  little  discomfort  felt  by  the  wearer.  A  large  number  of 
appliances  used  are  of  no  value,  simply  because  they  do  not  meet 
the  conditions  indicated  by  the  disease,  which,  varying  in  different 
cases,  remain  the  same  in  principle,  viz.,  the  fixation  of  the  spine 


62 


ORTHOPEDIC  SURGERY. 


in  such  a  position  that  the  jar  on  the  vertebral  bodies  shall  be  re- 
duced to  a  minimum  or  entirely  removed.  This  position  (aside 
from  recumbency  and  suspension)  would  be,  if  possible,  with  the 


Fig.  69. — Diagram  showing  Spinal 
Column  with  the  Usual  Relation  of 
the  Bodies  in  Caries  of  the  Spine. 


Fig.  70. — Position  of  Diseased 
Bodies  made  Worse  by  Flexion 
of  Spinal  Column. 


Fig.  71. — Diagram  of  Ca- 
rious Spine  Straightened  by 
Mechanical  Support. 


spinal  column  bent    backward  (concavity  backward),  so  that  the 
point  of  disease  would  be  in  front  of  the  line  of  superincumbent 


Fig.  72.  Fig.  73. 

Figs.  72  and  73. — Modified  Jury-mast  Before  and  After  the  Sling  is  Tightened. 

weight,  rather  than  behind  it.     This  (as  the  diseased  portions  are 
the  vertebral    bodies    in    front    of    the    hinge   of    motion,  viz.,  the 


POTT'S  J)/SJwlSK  63 

articulation)  would  tend  to  piy  the  diseased  bodies  apart  if  the 
spine  were  flexible,  or  diminish  the  superimposed  pressure.  "To 
straighten  the  spinal  column  in  such  a  manner  that  the  weight  of 
the  body  is  borne  on  the  transverse  processes,  and  not  by  the 
bodies  of  the  vertebra;,"  as  has  been  proposed,  is  not  possible  if 
any  disease  exists  sufficient  to  cause  a  projection.  This  has  been 
proved  in  experiments  on  the  cadaver,  and  in  suspension  of  patients 
the  projection  at  the  diseased  portion  does  not  disappear.  It  is 
possible,  however,  to  diminish,  by  suspension,  recumbency,  or  cer- 
tain positions,  the  amount  of  inter-vertcbral  pressure  at  the  point 
of  disease,  and  to  fix  or  nearly  fix  the  spine  in  the  corrected  posi- 
tion. 

Practically  the  choice  comes  down  to  one  of  two  appliances :  the 
plaster  jacket  and  its  modifications,  and  the  posterior  steel  brace, 
which  acts  on  the  transverse  processes  of  the  vertebrae  as  a  lever 
to  modify  the  pressure  between  the  diseased  vertebrae.  In  the 
cervical  region  the  various  collars  come  in  for  consideration. 

Other  appliances  are  numberless,  and  are  .chiefly  modifications  of 
one  or  the  other  of  these  standard  methods  of  treatment. 

TJie  Treatment  by  Plastej' Jackets. — The  most  ready  method  of 
fixation  is  by  means  of  Sayre's  plaster  jacket,  which  may  be  applied 
while  the  patient  is  suspended  or  recumbent. 

It  was  originally  supposed  that  a  jacket  could  be  applied  so  as 
to  serve  as  a  means  for  holding. the  diseased  vertebrae  apart,  i.e.,  as 
a  means  of  distraction.  Suspension  having  pulled  the  vertebrae 
apart,  a  jacket  which  takes  its  base-bearing  on  the  pelvis  and  a 
purchase  on  the  thorax,  would  keep  these  portions  from  coming 
together  by  a  vertical  support.  These  ideas  are  erroneous.  Sus- 
pension straightens  the  spinal  column  as  far  as  possible  and  re- 
moves antero-posterior  curves,  and  the  application  of  a  plaster 
jacket  prevents  the  column  from  bending  forward.  Plaster  jackets 
are  efficient  not  as  a  means  of  fixation  alone,  or  of  distraction,  but 
as  a  means  of  securing  comparative  fixation  in  an  improved  posi- 
tion. The  treatment  by  plaster  jackets  requires  care,  for  a  poor 
jacket  does  harm  rather  than  good  by  deceiving  the  physician  and 
the  patient.  For  the  proper  applying  of  plaster  jackets,  moreover, 
a  careful  attention  to  detail  is  necessary. 

Bandages  are  prepared  by  rolling  loose-meshed  cloth  in  dry 
plaster-of-Paris.  The  cloth  to  be  chosen  is  that  capable  of  carry- 
ing the  most  plaster-of-Paris,  and  presenting  as  little  cloth-fibre  as 
possible.  Crinoline  muslin  will  be  found  to  answer  this  purpose. 
The  plaster  is  to  be  rubbed  in  smoothly  and  to  be  freed  from 
lumps  or  unevenness.  The  patient's  clothes  are  removed  and  a 
thin,  tightly-fitting  undershirt  applied,  made  so  as  to  present  no 


64 


ORTHOPEDIC  SURGERY. 


wrinkles.  The  patient  is  then  suspended ;  the  head  is  secured  in  a 
sHng,  which  is  attached  to  a  strong  cord  playing  in  a  pulley,  or 
series  of  pulleys,  fastened  to  a  strong  point  above  the  patient's 
head.  An  assistant  pulling  on  the  cord  raises  the  patient  so  that 
the  heels,  and  if  necessary  the  toes,  are  free  from  the  floor.  It  is 
desirable  to  diminish  the  strain  upon  the  neck,  and  padded  loops 


Fig.  74. — Application  of  Plaster  Jacket. 


connected  with  the  bar,  which  is  raised  by  the  cord  and  pulley,  can 
be  passed  under  each  axilla,  or  handles  may  be  held  in  each  hand, 
connected  with  cords  which  play  over  pulleys.  A  pull  on  the  cords 
pulls  up  the  arms,  raising  the  patient.  It  should,  however,  be 
remembered  that  strain  upon  the  arms  or  scapulae,  connected  as 
they  are  to  the  spinal  column  by  the  trapezius  and  the  latissimus 
dorsi,  does  not  tend  to  straighten  the  upper  part  of  the  spinal 
column.     Pads  are  placed  over  the  crests  of  the  ilium,  and  a  large, 


J'OTTS  J)fSI':ASE.  65 

soft  pad  over  the  abdomen.  This  latter  is  to  be  pulled  out  when 
the  jacket  has  become  hard,  and  prevents  too  great  pressure  on 
the  abdomen. 

The  bandages  are  placed  singly  on  end  in  water  and  kept  im- 
mersed until  they  are  thoroughly  wet  {i.e.,  until  air-bubbles  no 
longer  rise  in  the  water  from  the  immersed  bandage)  and  are  then 
wound  smoothly  around  the  patient. 

If  the  plaster  is  fresh  and  of  the  best  quality,  it  should  harden 
in  from  five  to  ten  minutes.  The  hardening  can  be  hastened  by 
putting  salt  or  alum  in  the  water,  but  this  makes  the  plaster  some- 
what more  brittle.  After  the  plaster  is  hard  or  nearly  hard,  the 
patient  is  to  be  placed  on  a  soft  flat  surface,  care  being  taken  not 
to  crack  the  plaster  in  so  doing.  The  abdominal  pad  is  then  re- 
moved, and  the  edges  of  the  bandages  are  smoothed  down  and  cut 
off  if  they  press  uncomfortably  on  the  thighs  or  axillae. 

It  is  important  that  the  jacket  should  be  strong  in  front  as  well 
as  behind,  and  should  be  wound  as  high  as  possible  in  front,  in 
order  to  prevent  the  spinal  column  from  falling  forward.  If  the 
jacket  become  broken,  it  should  be  removed,  and  another  applied. 

Chafing  can  usually  be  prevented  by  careful  padding  on  each 
side  of  the  prominent  vertebral  process  and  over  the  hips.  For 
the  former,  the  stuffed  finger  of  a  kid-glove  will  often  answer,  but 
saddler's  felt,  cut  of  the  appropriate  thickness,  will  answer  better. 

It  is  important  that  the  proper  material  should  be  used  for  the 
bandages.  Too  close-meshed  a  cloth  cannot  retain  enough  plaster 
in  its  fibre,  and  holds  the  moisture  too  long  to  admit  of  rapid  hard- 
ening, which  is  an  essential  of  a  suitable  jacket ;  and  a  too  coarse- 
meshed  tissue,  as  mosquito-netting,  while  allowing  rapid  setting, 
makes  a  jacket  which  is  liable  to  chip  and  is  not  sufficiently  durable. 

Felting  has  been  prepared  which,  when  subjected  to  heat,  be- 
comes soft,  but  stiffens  on  cooling.  This  has  been  used  as  a  sub- 
stitute for  plaster-of-Paris  corsets.  (Cocking:  Brit.  Med.  Journal. 
1878,  p.  283.) 

If  the  disease  is  in  the  cervical  region,  the  plaster  bandages  can 
be  carried  up  around  the  back  of  the  head  and  neck,  leaving 
the  face  and  upper  part  of  the  head  exposed,  and  so  fixation  and 
support  may  be  obtained  in  that  part  of  the  vertebral  column. 

This  method  of  fixation  has  certain  manifest  disadvantages  in 
lack  of  cleanliness,  clumsiness  and  unsightliness,  but  it  is  thorough 
and  furnishes  an  excellent  support  and  is  by  no  means  uncomforta- 
ble for  the  patient. 

With  the  proper  application  of  the  plaster  jacket  began  a  new 
era  in  the  treatment  of  Pott's  disease,  and  for  this  much  honor  is 
due  to  Dr.  Sayre,  who  was  so  influential  in  bringing  this  useful 
5 


66 


ORTHOPEDIC  SURGERY. 


measure    to    the    notice    of    the    profession.     It    brought   a  ready 
means  of  treatment  within  the  reach  of  thousands  of  patients  who 


Fig.  75.— Appliance  for  Suspension. 


Fig.  77  — Beely  Method  of  Suspension 


Fig.  76.— Suspension  Sling,  German  Pattern.  Fig.  78.— Schreiber's  Method  of  Suspension. 


POTTS   DISJiASJ':. 


67 


could  not  have  been  helped  by  tlie  prevalent  methods  of  treat- 
ment. 

Plaster  jackets  have  certain  great  advantages  when  ijro[)crIy 
applied.  In  appropriate  cases  they  are  efficient  and  the  surgeon 
is  in  no  way  dependent  on  the  instrument  maker;  they  cannot  be 
loosened  at  the  whim  of  the  patient  and  remain  as  the  surgeon 
leaves  them.  On  the  other  hand,  plaster  jackets  not  being  remova- 
ble are  uncleanly  and  to  many  patients  uncomfortable  on  that 
account;  occasionally  an  obstinate  eczema  will  develop  underneath 
the  jacket. 

Plaster  jackets  can  be  applied  to  patients  lying  in  a  recumbent 


Fig.  79. — Finished  Plaster  Jacket  Cut 
and  Laced. 


Fig.  So. — Silicate  of  Potash  Bandage 
Jacket. 


position  slung  in  a  thin  cloth  hammock.  The  bandage  is  wound 
about  hammock  and  patient  and  the  ends  of  the  hammock  cut  off; 
or  several  sheets  of  crinoline  wet  in  plaster  may  be  wound  layer 
by  layer  about  the  patient  while  recumbent  or  when  suspended. 
The  usual  way,  however,  will  be  found  to  be  the  readiest. 

Plaster  jackets  may  be  split,  furnished  with  lacings  and  applied 
and  removed  at  will ;  they  lose  thereby  a  part  of  their  efficiency, 
as  they  may  be  improperly  reapplied  by  the  patient. 

But  with  careful  parents  and  attention  plaster  jackets  lose  but 
little  of  their  efficiency  if  they  are  carefully  split  down  the  front 
and  removed  before  they  dry.     They  should  at  once  be  placed  in 


68 


ORTHOPEDIC  SURGERY. 


the  same  shape  that  they  were  in  before  removal  and  tightly- 
bandaged  to  keep  them  from  warping,  as  they  will  if  let  alone.  In 
one  way  they  gain  in  efificiency  by  being  laced,  because  as  the 
jacket  becomes  somewhat  worn  it  can  by  tighter  lacing  be  made 
to  fit  the  back  more  closely.  As  applied  by  Dr.  Sayre  the  present 
plaster  jackets  are  split  and  laced,  and  by  this  they  gain  wonder- 
fully in  cleanliness  and  comfort. 

The  neatest  and  most  acceptable  form  of  jacket  is  one  applied 
over  a  seamless  woven  shirt.  These  shirts  are  made  very  long  and 
reach  the  knees;  one  of  them  is  put  on  the  patient  and  the  jacket 
applied  over  it.     The  lower  part  of  the  shirt  is  then  turned  up 


Fig.  8i. 


-Beely's  Felt  Jacket  with  Double 
Jury-mast. 


Fig.  82. — Owen's  Felt  Corset  with  Head 
Attachment. 


over  the  outside  of  the  jacket  and  reaches  to  the  top  of  it.  It  is 
there  stitched  to  the  upper  part  of  the  shirt  along  the  upper  edge 
of  the  jacket.  This,  however,  is  not  done  until  the  jacket  has  been 
removed,  by  splitting  it  down  the  front  and  gently  springing  it 
open.  The  edges  of  the  cut  are  stitched  with  leather  and  a  row  of 
hooks  is  provided  on  each  side  with  which  to  lace  it  together.  A 
jacket  is  thus  provided,  which  is  covered  inside  and  outside  with 
soft  woolen  material,  which  can  be  removed  for  purposes  of  clean- 
liness and  reapplied  to  the  patient,  who  should  be,  of  course,  sus- 
pended for  each  re-application.  A  plaster  jacket  is  only  ef^cient  in 
disease  below  the  seventh  dorsal  vertebra;  if  the  disease  is  situated 
higher  up  than  this  the  addition  of  a  head  piece  is  necessary. 

As  a  substitute  for  plaster  jackets,  corsets  are  made  of  leather,. 


POTT'S   DISEASE. 


69 


felt,  or  glue.  The  plaster  jacket,  which  is  applied  in  the  usual  way, 
is  removed  with  care,  so  as  to  preserve  its  shape.  A  plaster  mould 
is  taken,  and  on  this  as  a  form  a  corset  is  made  of  sole  leather 
(which  when  wet  can  be  stretched 
tightly  over  the  form),  by  winding 
bandages  or  strips  of  paper  soaked  in 
silicate  of  potash  or  glue  about  the 
mould.  Felt  impregnated  with  glue 
has  also  been  used.  After  this  has  be- 
come hard,  it  can  be  split  and  furn- 
ished with  eyelets  and  lacings;  it  can 
then  be  applied  on  the  patient,  who 
is  suspended,  as  in  the  application  of  a 
plaster  jacket.  The  leather  jackets 
for  heavy  patients  need  the  reinforcements  of  strips  of  steel,  which 
should  be  accurately  fitted  to  the  mould  and  firmly  secured  on 
the  jacket.  These  corsets  are  more  neat  and  more  durable  than 
plaster  jackets,  but  require  more  time  in  their  manufacture. 

The  figure  shows  the  leather  jacket  made  and  used  by  Dr.  Vance, 
of  Louisville.  It  is  so  simple  in  its  manufacture  and  construction 
that  it  can  be  made  by  the  physician  if  need  be. 


Fig.  83.— Walsham's  Felt  Cuirass. 


Vance  s  Leather  Jacket. 


-Cloth  Corset. 


A  cloth  corset  reinforced  with  wire  and  strips  of  steel  has  been 
used,  and  it  has  been  found  of  relief  and  benefit  in  certain  cases ; 
but  when  perfect  fixation  is  required,  the  arrangement  is  not  as 
reliable  as  firmer  corsets. 

In  the  upper  dorsal  and  cervical  region,  it  is  necessary  either  to 
add  to  the  plaster  jacket  an  appliance  for  securing  the  head  (the 


70 


ORTHOPEDIC  SURGERY 


varieties  of  which  will  be  mentioned  later),  or  to  carry  the  plaster 
jacket  over  the  shoulders  and  neck. 

A  plaster  collar  applied  simply  to  the  neck,  and  not  to  the  trunk, 
does  not  give,  sufficient  support  except  in  disease  of  the  upper  cer- 
vical vertebra,  though  it  has  been  occasionally  used. 

The  figures  illustrate  methods  of  supporting  the  head  in  cervical 
caries  devised  by  Dr.  Benj.  Lee,  of  Philadelphia. 

.  An  antero-posterior  support,  devised  by  Dr.  C.  Fayette  Taylor, 
is  suitable  for  use  in  emergencies.     It  consists  of  several  thicknesses 


Fig.  86. 


Fig,  87. 


Fig.  86  and  87. — Lee's  Method  of  Suspension  in  Cervical  Caries. 

of  blotting  paper,  saturated  in  shellac  and  moulded  to  the  patient's 
back.  The  shape  of  the  paper  should  be  similar  to  that  of  the  back 
of  a  man's  vest.  When  the  shellac  is  dry,  buckles  can  be  attached. 
These  buckle  on  an  apron  in  front,  and  pad  plates  of  blotting  paper 
can  be  added  inside.  For  permanent  wear  the  jacket  is  not  suitar 
ble.  The  shellac  is  softened  by  the  perspiration.  The  jacket  is, 
moreover,  very  hot  and  induces  profuse  sweating  of  the  back,  so 
that  it  requires  constant  repainting  with  shellac,  without  that  it 
becomes  soft,  and  unless  it  be  carefully  looked  after,  smells  offens- 
ively. 


j'OTTS  nisiCAsi-:.  71 

In  all  forms  of  head  supports,  if  worn  for  a  long  time,  a  cer- 
tain amount  of  recession  of  the  chin  takes  place.  The  nature  of 
this  is  not  clearly  understood,  but  the  growth  of  the  lower  jaw  is  in 
a  measure  temporarily  interfered  with,  and  the  front  teeth  in  the 
lower  jaw  can  in  severe  cases  not  articulate  with  those  of  the  upper. 
The  distortion  results  from  the  continued  use  of  any  form  of 
head  support,  and  is  more  liable  to  occur  the  more  efficient  the 
support.  The  jaw  gradually  resumes  its  shape  after  removal  of 
the  head  support. 

Objections  to  the  Plaster  Jacket. — The  theory  of  the  plaster  jacket 
seems  founded  upon  a  misapprehension,  namely,  that  the  deform- 
ity is  partly  obliterated  by  suspension.  There  is  a  certain  amount 
of  lengthening  of  the  spine  produced  by  thorough  suspension,  but 
it  is  obtained  by  the  obliteration  of. the  physiological  and  compen- 
satory curves  and  not  by  any  decided  change  in  the  outline  of  the 
deformity.  The  deformity  is  often  greater  when  the  patient  is  in 
the  upright  position  than  when  he  is  lying  on  the  face  or  suspended 
from  a  suspension  appliance. 

Even  if  it  were  possible  to  distract  the  diseased  vertebrae,  it 
would  not  be  desirable  by  this  or  by  any  other  method,  because  it 
would  separate  the  diseased  surfaces  and  leave  an  angular  gap  be- 
tween them  which  must  be  filled  by  some  solid  material  before  any 
weight-bearing  function  could  be  resumed  by  the  column.  It  is 
rather  desirable  than  otherwise  to  keep  the  diseased  surfaces  to- 
gether if  undue  pressure  can  be  overcome,  though  it  is  advisable  to 
reduce  the  pressure  from  superincumbent  weight  as  far  as  is  possi- 
ble which  crowds  together  the  inflamed  and  softened  vertebr^E. 

But  suspension  can  be  depended  upon  to  modify  the  pressure 
between  the  diseased  vertebra.  Unfortunately,  however,  the  plas- 
ter jacket  does  not  of  itself,  by  its  hold  upon  the  thorax,  maintain 
a  continued  extension,  but  the  jacket  and  the  thorax  so  adapt 
themselves  to  each  other  that  active  suspension  ceases.  The  jacket, 
however,  does  act  as  an  antero-posterior  support  until  it  becomes 
loose  and  inefficient. 

The  practical  objections  to  the  plaster  jacket  are : 

First. — It  becomes  loose  and  fits  badly  after  being  worn  for 
some  time,  and  furnishes  at  the  best  an  inaccurate  support  to  the 
diseased  column.  Every  change  in  the  size  of  the  abdomen  affects 
its  bearing  upon  the  back,  and  the  size  of  the  abdomen  changes  at 
every  meal.  One  has  only  to  examine  a  plaster  jacket  which  has 
been  worn  for  some  time  to  see  how  loosely  it  fits  in  parts.  Often, 
indeed,  the  hand  can  be  inserted  between  the  jacket  and  the 
chest. 

Second. — It  is  hot  and  dirty  unless  it  is  so  made  as  to  be  remov- 


72  ORTHOPEDIC  SURGERY. 

able,  and  that  requires  considerable  pains  on  the  part  of  the  sur- 
geon. Moreover,  when  a  patient  is  careless,  bread  crumbs,  food, 
and  vermin  find  their  vi^ay  under  the  jacket. 

Third. — The  jacket  is  very  liable  to  chafe.  Sometimes  it  causes 
deep  ulcers  under  it.  Especial  pains  should  be  taken  to  remove 
the  jacket  at  once  if  the  child  should  have  an  eruptive  disease,  such 
as  measles  or  scarlet  fever,  for  ulcers  are  very  likely  to  form  under 
it  during  these  diseases.  In  a  word,  the  theory  of  the  jacket  is 
based  upon  a  misapprehension.  It  is  in  reality  an  antero-posterior 
brace  which  lacks  much  of  being  perfectly  efficient,  and  it  is  dirty 
and  hot  and  liable  to  chafe  the  skin  underneath. 

But,  on  the  other  hand,  it  must  be  said  that  it  is  the  best  and 
most  efficient  mode  of  treating  certain  cases. 

When  a  lateral  deviation  of  the  spinal  column  is  present  with 
Pott's  disease,  the  jacket  is  preferable  to  any  brace. 

In  disease  which  is  very  low  down,  the  jacket  is  often  a  more 
efficient  and  comfortable  mode  of  treatment.  For  careless  and 
ignorant  patients  a  jacket  which  is  not  removable  is  far  preferable 
to  any  apparatus  which  they  can  misuse. 

Moreover,  the  cheapness  of  the  jacket  brings  it  within  reach  of 
many  people  who  would  otherwise  have  to  go  without  treatment. 

The  experience  of  an  Italian  surgeon,  Motta,'  is  of  interest  with 
regard  to  the  use  of  the  plaster  jacket.  He  has  applied  the  Sayre 
jacket  some  1,200  times  and  he  reports  most  satisfactory  results 
from  its  use.  The  time  required  for  treatment  was  from  eighteen 
months  to  two  years. 

Treatment  by  Means  of  Braces. — Besides  the  objections  to  fixed 
plaster  corsets  mentioned,  this  adverse  criticism  may  be  urged,  viz., 
that  the  back  cannot  be  readily  inspected  nor  the  pressure  easily 
altered  from  day  to  day,  if  the  spinal  column  has  become  altered 
in  shape  or  if  the  appliance  has  slipped.  For  proper  treatment  by 
fixation  of  the  spinal  column,  it  is  important  that  there  should  be 
little  or  no  forward  and  backward  movement  near  the  diseased  ver- 
tebrae. 

To  obtain  this  the  spinal  column  should  be  made  as  nearly 
straight  as  is  possible,  and  the  trunk  prevented  from  bending  for- 
ward by  means  of  backward  pressure  on  the  upper  and  lower  part 
of  the  trunk,  and  forward  pressure  on  the  spinal  column  at  the  dis- 
eased point.  It  will  be  seen  that  if  the  corset  slip,  the  back  changes 
in  shape,  so  that  the  pressure  will  come  in  such  a  way  that  the 
spinal  column  is  pushed  forward  above  the  point  of  disease,  and 
the  appliance  will  then  be  an  injury.  A  brace  should  work  on  the 
principle  of  a  lever,  the  fulcrum  being  the  diseased  point  of  the 
'  Annual  Univ.  Med.  Sci.,  1889,  Vol.  iii.,  pp.  5-7. 


POTTS  J)  IS  EASE. 


73 


spinal  column,  and  the  power  should  be  applied  so  that  the  part 
above  the  diseased  vertebrae  is  held  back  as  far  as  possible,  thus 
diminishing  the  inter-vertebral  pressure  at  the  diseased  point.  This 
is  true,  whether  the  appliance  is  a  steel  brace  or  a  plaster  corset, 
but  the  regulation  and  inspection  of  the  fulcrum  are  more  readily- 
attained  in  a  brace,  if  properly  constructed  and  allowing  adjust- 
ment, than  in  a  corset,  the  manufacture 
of  which  involves  much  labor. 

The  construction  and  application  of 
a  brace  should  be  superintended  di- 
rectly by  the  surgeon.  The  details  rel- 
ative to  the  future  result  are  fully  as 
important  as  the  application  of  a  splint 
in  any  fracture,  for  the  result  will,  in  a 


Fig. 


-Diagram  of  Antero-posterior  Support ; 
Side  View. 


Fig.  89. — Diagram  of  Antero-posterior  Support ; 
Back  View. 


great  measure,  depend  on  the  accuracy  of  adjustment.  For  the 
construction  of  a  splint  a  tracing  of  the  back  should  be  made. 
This  is  done  as  follows :  The  patient  lies  upon  a  hard  surface,  and 
a  strip  of  flexible  metal  (lead  or  a  mixture  of  lead  and  zinc)  strong 
•enough  to  retain  its  position,  and  pliable  enough  to  be  readily  bent, 
is  laid  upon  the  back,  from  the  neck  to  the  sacrum,  so  as  to  accu- 
rately fit  the  lines  of  curve  presented  by  the  spinal  column.  The 
lead  is  removed,  laid  on  its  side  upon  a  piece  of  stiff  card-board  and 
the  inner  outline  traced.  This  not  only  serves  as  a  record,  but  can 
he  used  for  a  sfuide  in  the  construction  of  the  brace. 


74 


OR  THOPEDIC  S  URGER  V. 


Different  forms  of  appliances  have  been  recommended  for  the 
treatment  of  Pott's  disease.  The  first  efificient  and  thorough  adap- 
tation of  the  principles  of  treatment  by  proper  antero-posterior 
supports  has  been  accomplished  by  Dr.  C.  Fayette  Taylor,  of  New 
York.  Since  the  use  of  appliances  advocated  by  him  some  modifi- 
cations have  been  introduced,  but  the  principles  under  which  he 
worked  have  remained  much  the  same. 


Fig.    go. — Antero-posterior  Back  Brace 
of  Ordinary  Pattern. 


Fig.  91. — Brace  with  Band  at  Bottom  instead  of  V 
piece;  also  applied  with  Swathe. 


The  simplest  antero-posterior  apparatus  consists  of  two  uprights 
of  annealed  steel,  three-eighths  or  one-half  of  an  inch  in  width  and 
thick  enough  to  be  rigid.  The  gauge  numbers  of  the  steel  as  to 
thickness  should  be  eight  to  twelve.  These  uprights  should  reach 
from  just  above  the  posterior  superior  iliac  spines  to  about  the 
level  of  the  second  dorsal  vertebra.  The  uprights  are  joined  to- 
gether below  by  an  inverted  (J-shaped  piece  of  steel  which  runs  as 
far  down  on  the  buttock  as  possible  without  reaching  the  chair  or 


POTTS    niSlwlSE. 


75 


bench  when  the  patient  sits  down.  Or  the  brace  may  end  in  a 
waist-band,  as  is  shown  in  the  fij^ures.  The  uprights  are  joined 
above  by  another  U-shaped  piece,  the  upper  ends  of  which  should 
pass  over  to  the  anterior  as^ject  of  the  elevation  of  the  shoulders, 
or  rather  to  the  root  of  the  neck. 

The  uprights  should  be  far 
enough  apart  to  support  the 
transverse  processes  of  the 
vertebra;,  and  not  the  spinous 
processes.  They  should  be 
bent  according  to  a  cardboard 
tracing  of  the  back,  taken  as 
described,  and  then  adjusted 
to  the  back.  The  neck  and 
bottom  pieces  should  be  cut 
out  in  cardboard  in  pattern. 
The  whole  should  then  be  riv- 
eted together  and  tried  on  the 
patient,  who  should  be  lying 
on  his  face  in  the  recumbent 
position.  Any  alteration  nec- 
essary in  the  curves  of  the 
steel,  in  order  to  have  the  ap- 
pliance fit  closely  to  the  back 
along  its  whole  length,  can  be 
made  with  wrenches.  The 
brace  can  be  wound  with 
strips  of  canton  flannel,  faced 
with  hard  rubber,  and  covered 
with  chamois,  or  be  covered 
smoothly  with  leather.  An 
accurate  fit  is  essential,  the 
covering  is  merely  a  matter  of 
detail. 

Pad  plates  covered  with  felt 
or  hard  rubber,  are  needed. 
In  some  instances,  at  the 
points  of  greatest  pressure 
(the  fulcrum  of  the  lever,  etc.)  the  bars  of  the  brace,  if  well  pad- 
■ded,  answer  every  purpose.  Buckles  are  needed  at  the  ends  of  the 
neck  piece,  at  a  level  with  the  axilla,  opposite  the  middle  of  the 
abdomen,  and  at  the  lower  end  of  the  brace. 

If  properly  designed  the  appliance  will  press   firmly  at  the  ful- 
crum. I.e.,  the  pad-plates  and  pressure  should  be  uniform  at  this 


Fig.  92. — Antero-posterior  Support  Applied. 
Tavlor. 


y6  ORTHOPEDIC  SURGERY. 

point  and  closely  fitted  to  the  contour  of  the  curve.  The  appliance 
will  also  touch  necessarily  at  the  top  and  bottom,  but  the  chief 
pressureshould  be  at  the  points  designed  as  fulcrum.  Variations 
from  this  type  of  construction  will  naturally  be  of  use.  The  sim- 
plest is  the  following:  Instead  of  an  upright  of  a  single  piece  to 
which  a  pad-plate  is  attached,  an  upright  of  three  pieces  may  be 
used,  the  pad-plate  being  separate,  and  fastened  to  two  steel  strips 
extending  above  and  below.  This  arrangement  allows  the  sections 
to  be  taken  apart  and  carefully  adjusted,  but  is  somewhat  more 
complicated.  Instead  of  the  band  at  the  bottom,  a  curved  piece  of 
steel  is  sometimes  of  advantage,  in  avoiding  pressure  in  the  middle 
of  the  sacrum  and  allowing  careful  adjustment.  Nicety  of  work- 
manship in  the  manufacture  of  a  brace  is  of  relatively  secondary 
importance.  The  essential  is  that  it  should  be  mechanically  effi- 
cient in  meeting  the  indications  of  fixation.  The  construction  of 
the  brace  does  not  necessarily  involve  expensive  workmanship, 
and  need  not  be  anything  beyond  the  skill  of  a  village  black- 
smith. It  should  be  borne  in  mind  that,  besides  accuracy  of  fit 
and  proper  design,  it  is  of  importance  that  the  apparatus  be  stiff 
enough  so  as  not  to  yield  as  the  weight  of  the  trunk  falls  upon  it, 
inasmuch  as  yielding  involves  inter-vertebral  pressure.  This  is  true 
not  only  of  the  uprights,  but  also  of  the  band.  A  stiff  appliance, 
if  properly  fitted,  can  be  made  as  comfortable  as  a  yielding  one, 
and  is  much  more  efficient. . 

It  is  surprising  how  small  an  error  in  the  direction  of  inac- 
curacy of  fit  will  excite  pain.  Moreover,  it  is  necessary  that  the 
patient  should  be  seen  often  enough  to  keep  the  brace  fitting  ac- 
curately, for  the  deformity  may  increase  or  diminish  at  any  time. 
In  such  a  case  the  brace  becomes  inefficient. 

It  is,  of  course,  essential  that  the  trunk  be  properly  secured  to 
the  brace.  This  can  be  done  by  means  of  an  apron,  which  covers 
the  front  of  the  trunk,  the  abdomen,  and  the  chest,  reaching  from 
the  clavicles  nearly  to  the  symphysis  pubis.  The  apron  is  provided 
with  webbing  (non-elastic)  straps,  which  are  fastened  into  buckles 
attached  to  the  brace.  Padded  straps,  passing  from  the  top  of  the 
brace  around  the  arms,  under  the  axillae,  and  attached  to  buckles  in 
the  middle  of  the  brace,  help  to  secure  it;  but  the  scapulae,  being 
movable,  cannot  be  relied  upon  alone  to  fix  the  trunk,  and  the 
apron  must  be  furnished  with  straps  at  the  top,  which  pass  over 
the  shoulders  to  buckles  in  the  top  of  the  brace. 

In  adults  it  is  often  convenient  to  have  the  apron  split  down  the 
front  and  provided  with  webbing  straps  and  buckles.  It  can  then 
be  adjusted  by  the  patient  himself  without  touching  the  straps  at 
the  back  which  secure  the  apron  to  the  brace. 


POTTS   DISl'.ASE. 


77 


A  useful  addition  in  certain  cases  of  dorsal  caries  is  found  in  tlie 
use  of  Dr.  Taylor's  chest  piece,  which  is  shown  in  the  fi^^ure.  \^y 
means  of  hard-rubber  pads  a  definite  counter  point  of  pressure  is 
furnished  at  the  upper  part  of  the  chest  which  keeps  the  brace 
closely  against  the  back.     The  pads  of  the  chest  piece  may  be  made 


Fig.  93. — Apron  for  the  Antero-superior  Support. 


of  hard-rubber  and  fit  in  below  the  clavicles,  where  they  cause  no 
discomfort  and  restrict  the  chest  movements  less  than  the  apron, 
beside  affording  more  definite  support. 

The  brace  should  be  worn  day  and  night,  and  removed  daily  that 
the  back  may  be  bathed.  While  the  brace  is  off,  the  patient  should 
lie  on  the  face  or  the  back.  On  no  account  should  he  sit  erect. 
The  back,  after  being  washed,  should  be  rubbed  with  alcohol  and 
then  powdered  with  face  powder,  corn  starch,  or  Pear's  fuller's 
earth.  The  brace  should  then 
be  applied  and  buckled  tightly 
into  place. 

Chafing  of  the  back  is  some- 
times unavoidable  in  summer. 
When  a  severe  chafed  spot  forms, 
the  brace  must  be  removed  for 
the  time  and  the  child  lie  flat  in 
bed  until  the  ulcer  heals. 

Dr.  Judson  formulates  a  gen- 
eral rule  which  may  serve  as  a 
guide  in  the  treatment  of  Pott's  disease  by  rigid  apparatus,  espe- 
cially in  all  forms  of  the  Taylor  brace.  The  rule  reads :  "  The 
apparatus  maybe  considered  as  having  reached  the  limit  of  its  effi- 
ciency if  it  makes  the  greatest  possible  pressure  on  the  projection 
compatible  with  the  comfort  and  integrity  of  the  skin." 

Certain  braces  have  a  tendency  to  "  ride  up,"  and  the  neck  pieces, 
instead  of  lying  closely  to  the  shoulders,  project  upward  in  a  most 


Fig.  94. — Taylor's  Chest  Piece. 


78 


ORTHOPEDIC  SURGERY. 


unsightly  way.  In  general,  this  does  not  occur  in  braces  which  fit 
accurately.  Sometimes,  however,  it  is  most  troublesome,  and  in 
these  cases  padded  perineal  straps  can  be  added  which  are  attached 
to  the  apron  in  front  and  to  the  lower  end  of  the  brace  behind. 
They  are,  however,  a  source  of  much  annoyance  to  children,  in 
urination  especially,  and  are  to  be  avoided  if  possible.  The  apron 
will  sometimes  be  found  to  cut  over  the  anterior-superior  spines 
of  the  ilium  and  also  under  the  arms,  and  must  be  properly  padded. 
In  applying  the  brace  the  patient  should  lie  upon  his  face,  and 
the  apron  be  spread  under  him.     The  brace  should  then  be  placed 

in  position  upon  the  bare  back,  or 
upon  a  thin,  smooth  cloth  per- 
mitting no  wrinkles,  and  the  apron 
strapped  to  it  as  tightly  as  is 
possible.  The  more  tightly  the 
two  are  strapped  together,  the 
more  thorough  is  the  fixation.  The 
position  of  the  straps  and  their 
number  will  vary  in  cases  accord- 
ing to  the  situation  of  the  disease, 
etc.  By  means  of  wrenches  and 
a  vice  the  uprights  can  be  bent  so 
as  to  secure  pressure  in  the  proper 
place,  and  a  proper  adjustment  is 
not  difficult. 

A  troublesome  complication  in 
the  use  of  the  antero-posterior 
brace  is  the  presence  of  a  late- 
ral curve  in  the  vertebral  column, 
this  has  been  m.entioned  as  an  oc- 
-Cocking's Poro-piastic  casioual  Complication  of  Pott's 
acket  with  Jury-mast,  ^igease.  The  bracc  fits  when  the 
child  lies  down,  but  when  he  sits  up,  the  column  leans  to  one  side 
again,  and  it  is  of  course  impossible  for  the  brace  to  fit  as  before. 
Fortunately,  this  symptom  passes  slowly  away  as  ef^cient  support 
is  afforded  to  the  column,  and  then  the  brace  fits  again.  Mean- 
time it  is  best  to  apply  the  brace,  bending  up  one  neck  piece  and 
bending  the  other  down  to  make  the  top  of  the  brace  set  squarely; 
it  is  also  best  to  keep  the  patient  in  a  recumbent  position  as  much 
as  possible  until  the  deformity  improves. 

The  application  of  the  therapeutic  principle  of  fixation  in  the 
best  possible  position  varies  according  as  the  disease  involves  the 
upper,  middle,  or  lower  parts  of  the  spinal  column. 

In  the  upper  region,  as  elsewhere,  it  is  desirable  to  prevent  the 


Fig.  95. — Nebel's 
Jury-mast. 


POTTS   /)  IS /CASK. 


79 


weight  of  the  head  from  falling  upon  the  diseased  bodies  of  the 
vertebrae.  This  can  be  done  in  the  cervical  region  by  suspension 
in  a  sling,  similar  to  that  used  in  ordinary  suspension  for  the  appli- 
cation of  plaster  jackets.  The  sling  passes  under  the  chin  and 
occiput,  and  is  connected  by  means  of  straps  to  a  bent  rod,  which 
arches  above  the  head  and  is  bent  around  the  head  and  neck,  being 
attached  below  to  a  plaster,  felt,  leather,  or  wire  corset.  The 
jacket  is  kept  from  slipping  down  by  means  of  pressure  on  the 
hips,  if  the  hips  are  large  enough  (which  is  rarely  the  case  in  chil- 


FlG.  97. 

Figs.  97  and 


Beely's  Felt  Jacket — Cervical  Caries. 


dren),  or  by  means  of  straps  passing  over  the  shoulders;  the  weight 
of  the  head  is  thus  transferred  to  the  shoulders  or  hips.  The 
amount  of  pressure  under  the  chin  and  occiput  would  in  some  in- 
stances be  such  that  it  would  be  impossible  for  the  patient  to  open 
his  mouth;  but  a  reduction  of  the  weight  of  the  head  on  the  cer- 
vical vertebras  is  easily  effected  in  this  way,  Avhich  also  prevents 
the  head  from  bending  forward. 

A  thoroughly  efificient  arrangement  is  one  used  by  Dr.  C.  F. 
Taylor,  of  New  York;  an  ovoid  steel  ring  passes  around  the  neck, 
made  so  that  it  can  open,  and  be  secured  when  closed,  and  ar- 
ranged so  that  it  can  serve  as  a  rest  for  the  chin,  and  so  that  pres- 


8o 


ORTHOPEDIC  SURGERY 


sure  can  also  be  exerted  on  the  occiput.     This  collar  at  the  back 

plays  on  a  pivot,  allowing  lateral  motion  of  the  head.  The  pivot 
is  attached  to  the  usual  back-brace,  and  can 
be  raised  or  lowered,  as  it  is  desired  to  increase 
or  diminish  the  upward  pressure  on  the  head. 
The  back-brace  should  be  supplied  with  pad- 
ded cross-pieces,  which  will  effect  counter- 
pressure  on  the  shoulders. 

This  appliance  requires  care  and  skill  in 
application,  and  is  useless  unless  properly 
fitted. 

The  problem  of  supporting  the  head  in  cer- 
vical caries  is  always  a  difficult  one  to  solve. 
The  brace  just  described  is  an  apparatus  which 

is  fitted  only  with  much  trouble  and  which  easily  transfers  so  much. 

of  its  weight  to  the  shoulder  pieces  that  chafing  is  inevitable. 
Other    forms    of  head    support 

have  been  tried  from  time  to  time. 

Some  of  them  have  been  useful. 

The  one  shown  in  the  figures  is 

a  continuation  of  the  two  uprights 


Fig.  99. — Head-rest  for  An- 
tero-posterior  Support. 


Fig.  100. — Antero-posterior  Brace  with 
Taylor  Head-piece. 


Fig.  ioi. — Antero-posterior  Support  Applied. 


on  the  back  of  the  head.     By  the  head  piece  the  head  and  neck 
are  held  firmly  back  against  the  forks  of  the  brace.     It  is  a  service- 


POTT'S   J) [SEAS E. 


8i 


able  brace  when  there  is  considerable  deformity  in  the  back  of  the 
neck  or  the  head  tends  to  fall  backward,  as  it  sometimes  does.  The 
chief  objection  to  it  lies  in  the  fact  that  it  is  a  m(jst  difficult  mat- 
ter to  so  shape  the  forks  that  they  will  follow  the  outline  f;f  the 
head  and  not  be  painful  by  undue  pressure  upon  any  one  point. 

A  separate  chin  rest  of  the  pattern  seen  in  the  figures  is  often 
used.  It  consists  simply  of  a  bent  wire  stout  enough  to  support 
some  weight  and  a  tin  pad  plate  bent  to  fit  the  curve  of  the  chest. 


■;?=»«i 


Fig.  I02.— Front  View  of  Antero-posterior  Support  for  Cervical  Canes,  Showing  Apron. 


It  is  adjusted  by  straps  running  to  the  brace  under  the  arms  and 
above  to  the  ends  of  the  neck-pieces.  It  is  worn  with  the  ordinary 
steel  antero-posterior  support,  and  is  a  very  useful  and  inex- 
pensive addition  in  cases  where  the  chin  tends  to  drop  upon  the 
chest,  in  cases  of  cervical  caries,  or  in  high  dorsal  caries,  where  a 
support  to  the  head  seems  indicated. 

A  brace  has   been  devised  by  Dr.  J.   E,   Goldthwaite,  formerly 
House  Surgeon  at  the  Children's  Hospital,  which  affords  most  ex- 
cellent fixation  in  cases  of  cervical  caries.     Its  construction  is  evi- 
6 


82 


OR  THOPEDIC  S  UR  GER  V. 


dent  from  the  figure,  and  it  seems  likely  to  be  serviceable  in  cases 
where  there  is  excessive  sensitiveness  of  the  spine. 

Collars  of  various  sorts,  unattached  to  any  other  appliance,  have 
been  used,  which,  pressing  on  the  chin  and  occiput  above,  and  on 
the  sternum  and  shoulders  below,  transfer  the  weight  in  part  from 
the  intermediate  cervical  vertebrae  and  check  the  forward  bowing 
of  the  cervical  region.  These  collars  can  be  made  of  plaster  of 
Paris,  but  are  cumbersome  and  unsightly;    leather  collars,  stuffed 


Fig.  103.— Form  of  Head  Support  for 
Cervical  Caries. 

with  sawdust,  as  used  by  Mr.  Thomas,  of  Liverpool,  will  be  found 
more  convenient. 

A  convenient  way  of  making  these  collars  of  Mr.  Thomas  is  by 
taking  a  piece  of  stout  webbing,  long  enough  to  go  loosely  around 
the  neck,  and  winding  it  with  sheet  wadding  or  oakum  until  it  is 
padded  sufficiently.  Then  it  should  be  covered  with  a  bandage 
outside  and  the  ends  of  the  webbing  should  be  buckled  together. 
The  patient  wears  the  collar  a  few  days  and  then  as  the  padding 
becomes  matted  down,  new  padding  is  added,  until  the  collar  is  the 
desired  size  and  shape.  It  is  then  sent  to  a  harness  maker  to  be 
covered  with  leather.  In  this  way  a  much  more  satisfactory  re- 
sult is  obtained  than  by  sending  measures  to  a  harness  maker  in 
the  first  place. 

A  collar  made  of  wire  netting,  moulded  to  the  shape,  and  rein- 


POTT'S    PfSlwlSli 


83 


forced  by  strips  of  steel,  is  much  more  sightly.  This  collar  was 
devised  by  Dr.  If.  L.  liurrell,  of  Boston.  It  is  made  of  li^dit  brass 
gauze  netting   and  paper   patterns  cut   of   a];j)roximately  the   re- 


Fig.  107. — Thomas's  Leather  Collar, 


Fig.  ioS. — Fonn  of  Head  Support  for  Cervical 
Caries. 


84 


ORTHOPEDIC  SURGERY. 


quired  size  and  shape.  Then  the  netting  is  shaped  to  the  neck  in 
two  pieces  and  sent  to  the  instrument  maker.  When  completed  it 
buckles  arouiid  the  neck,  and  is  useful  either  alone  or  as  the  head 
piece  to  a  modified  brace,  as  is  shown  in  the  figure. 

Collars,  however,  lack  in  steadiness,  and,  in  order  to  secure  ac- 
curate fixation  of  the  head,  they  should  be  connected  with  uprights 
which  extend  below  and  are  attached  to  the  trunk.  The  combina- 
tion of  a  collar  and  Taylor  back  brace  may  be  seen  in  the  figure.  • 

It  is  hard  to  say  just  when  the  need  for  a  head  support  begins. 


Fig.  109. — Back  View  of  Head-rest. 


Fig.  no.— Head-rest  for  Transferring  the 
Weight  of  the  Head  to  the  Shoulders  in  Cer- 
vical Pott's  Disease. 


In  general,  if  the  disease  is  above  the  fourth  dorsal  vertebra,  a 
head  piece  is  indicated.  Sometimes,  if  the  disease  is  lower  down, 
pain  makes  it  evident  that  a  head  support  is  needed  there  also. 

In  the  lower  cervical  and  upper  dorsal  region  it  is  difficult  to 
apply  suspension  efificiently  or  to  fix  the  spine  completely,  and  the 
treatment  of  caries  of  the  spine  in  this  region  requires  particular 
care  for  the  arrest  or  prevention  of  deformity.  The  means  to  be 
used  are  the  same  as  those  employed  In  cervical  caries. 

The  mechanical  treatment  of  disease  in  the  middle  region  is 
quite  satisfactory;  the  principle  of  leverage  can  be  applied  with 
thoroughness,  and  excellent  results  obtained. 


POTTS   DISEASE. 


85 


In  the  lowest  region — i.e.,  in  the  lumbar  region — it  is  difficult  to 
prevent  entirely  the  forward  bending  of  the  spinal  column,  and  in 
severe  cases  absolute  recumbency  is  the  best  treatment;  but  ex- 
cellent results  are  often  obtained  by  the  mechanical  treatment 
alone  of  these  cases,  for  the  reason,  probably,  that  the  bodies  in 
the  lumbar  regions  are  large,  and   in  some  cases  but  a  relatively 


Fig.  III. — Burrell's  Brass-wire  Collar. 


Fig. 


-Burrell's  Wire  Collar  Attached  to  Antero- 
posterior Support. 


small  portion  may  be  affected.  The  reconstruction  of  bone  is 
more  readily  established,  and  all  that  is  needed  is  a  certain  amount 
of  mechanical  support ;  the  applicance  should  reach  as  low  as  is 
possible. 

It  will  be  found  that  the  lateral  deviation  observed  in  caries  of 
the  spine,  unless  well-pronounced  change  in  the  shape  of  the  ver- 
tebrae has  taken  place,  will  disappear  without  difficulty  under  an 
efficient  antero-posterior  support. 


86  ORTHOPEDIC  SURGERY. 

H.  L.  Taylor  gives  nine  cases  where  recession  of  the  deformity- 
has  taken  place  under  treatment  by  the  Taylor  back-brace.  He 
states,  first,  that  "  the  average  ultimate  result  in  Dr.  C.  Fayette 
Taylor's  private  practice,  using  his  antero-posterior  leverage  sup- 
porting and  protective  apparatus,  thoroughly  and  for  a  sufficient 
length  of  time,  has  been,  under  favoring  conditions  of  attendance 
and  home  attention,  the  definite  arrest  of  the  deformity  at,  or  near 
the  point  it  had  reached  before  such  protection  was  furnished." 
In  certain  cases,  however,  he  notes  that  the  deformity  will  increase 
in  spite  of  all  care. 

The  straightening  of  the  curved  back  to  which  he  refers,  is  not 
merely  the  obliteration  of  the  compensatory  curves,  but  a  real 
diminution  or  disappearance  of  the  angular  projection.  The  cuts 
that  accompany  his  article  show  that  plainly  enough. 

Of  the  nine  cases,  one  was  dorsal  disease,  three  were  dorso-lum- 
bar,  five  were  lumbar  entirely.  In  five,  the  knuckle  completely 
disappeared,  while  in  the  others  the  improvement  was  very  marked. 
The  time  for  disappearance  ranged  from  three  to  ten  years  after 
the  beginning  of  treatment.  The  case  of  dorsal  disease  recovered 
wholly.     The  cases  are  given  in  full  in  the  article. 

The  chief  objection  to  the  use  of  mechanical  appliances  as  a 
method  of  treatment  is,  that  care  and  special  skill  are  required,  not 
only  in  the  application  of  braces,  but  in  the  inspection  and  manage- 
ment of  the  case. 

Faulty  Appliances. — Unless  an  appliance  works  in  the  way  the 
indications  of  the  disease  demand,  it  is  inefficient,  and  it  is  on  ac- 
count of  faulty  construction  that  appliances  have  often  been  found 
of  so  little  use.  A  most  common  fault  is  that,  in  order  that  the 
appliance  may  be  light,  the  steel  uprights  are  flexible  and  give 
under  pressure.  It  is  evident  that  any  appliance  which  allows 
bending  forward  of  the  spine  at  the  point  of  disease  does  not  re- 
lieve the  pressure  when  relief  is  most  needed.  A  second  fault  is 
that  the  trunk  is  often  not  thoroughly  fixed  by  the  straps,  etc.,  of 
the  appliance.  If  this  is  the  case,  the  brace  becomes  simply  a 
frame  of  steel  laid  upon  the  back,  and  not  a  therapeutic  agent. 
The  exact  situation  of  straps  must  vary;  they  should,  however, 
make  pressure  as  high  up  and  as  low  down  on  the  trunk  as  possi- 
ble. If  elastic  straps  are  used,  the  value  of  the  appliance  is  im- 
paired in  proportion  to  the  elasticity. 

It  is  of  the  greatest  importance  that  the  fulcrum  of  the  brace 
should  be  applied  to  the  right  portion  of  the  spine.  It  is  not  neces- 
sary that  the  uprights  should  be  applied  closely  to  the  whole  back, 
but  it  is  important  that  at  the  point  of  the  disease,  and  for  some 
distance  below,  the  pressure  should  be  thorough,  indicating  that  as 


POTT'S  J)ISI<:ASE.  87 

the  appliance  is  worn  but  little  motion  of  the  spine  at  that  j;oint 
is  possible.  The  pad-plates  should  be  arranged  so  that  they  may 
make  pressure  on  each  side  of  the  spines,  as  near  as  is  feasible  to 
each  other;  pressure  directly  on  the  spines  cannot  be  borne. 

The  use  of  a  crutch  attachment  to  a  brace  is  very  common,  and 
originated  from  the  fact  that  patients  often  lean  upon  tables,  or 
support  themselves  on  their  arms.  To  be  efficient,  a  crutch  should 
have  a  firm  base,  but,  attached  as  it  is  to  a  steel  waist-band,  it  af- 
fords no  certain  support,  and  is  therefore  of  doubtful  advantage. 
If  a  crutch  is  to  be  used,  it  should  reach  to  a  firm  base,  as  the 
floor.  Ordinary  crutches  (a  wheel-crutch)  act  in  this  way;  but  the 
pelvis  of  a  child  is  too  small  to  furnish  a  steady  base. 

If  the  brace  is  too  long  below,  the  patient  will  sit  upon  the  ends 
when  he  sits  down  and  force  it  up  at  the  neck. 

Objections  to  the  Steel  Antero-Posterior  Support. — Although  the 
brace  is  one  which  can  be  made  by  any  blacksmith,  the  directions 
for  its  construction  and  its  application  after  it  is  made  require  a 
definite  knowledge  of  its  structure  and  uses  on  the  part  of  the  sur- 
geon. It  is  not  an  apparatus  which  can  be  bought  of  an  instru- 
ment maker:  it  must  be  made  for  the  individual  case.  Many 
braces  are  furnished  by  the  stores  which  in  outward  appearance 
resemble  this  apparatus,  but  either  fit  so  badly  that  they  are  of  no 
value  or  are  entirely  wrong  in  the  principle  upon  which  they  are 
constructed.  Often  the  uprights  are  made  of  tempered  steel  and 
are  so  elastic  that  they  furnish  no  fixation  whatever  to  the  diseased 
vertebrae. 

The  utmost  care  in  the  fitting  and  use  of  the  brace  is  demanded 
both  on  the  part  of  the  surgeon  and  the  parents.  The  brace  can 
be  fitted  easily  with  two  monkey  wrenches,  but  it  requires  a  certain 
amount  of  painstaking.  On  the  part  of  the  parents,  the  brace 
must  be  daily  applied  with  care  and  the  patient  must  be  watched 
to  see  that  the  straps  are  kept  constantly  tight.  The  back  of  the 
patient  must  be  carefully  looked  after  to  prevent  chafing,  which  is 
sure  to  occur  in  the  careless  use  of  the  brace.  Chafing  often  is, 
inevitable  in  children  with  tender  skin,  but  much  can  be  done  to 
prevent  it  if  the  back  is  washed  daily,  rubbed  with  alcohol  and  kept 
carefully  powdered  during  warm  weather. 

Selection  of  a  Method  of  Treatment. — In  the  selection  of  mechani- 
cal supports  the  choice  will  lie  between  some  of  the  fixed  corsets 
of  plaster  of  Paris  (or  the  variations  of  that  form  of  corset  fixation) 
and  the  antero-posterior  supports  of  steel.  The  experience  of  the 
writers  would  lead  them  to  prefer  the  type  of  appliance  classified 
as  the  steel  antero-posterior  support  whenev^er  its  use  is  practicable. 

Some  skill  is  required  in  the  adjustment  of  appliances  of  this  sort, 


88  ORTHOPEDIC  SURGERY. 

but  not  more  than  can  be  readily  acquired  by  a  short  experience 
with  this  class  of  cases.  The  great  advantage  of  the  antero-pos- 
terior  support  is  that  it  can  be  more  accurately  adjusted  to  the 
back  and  kept  fitting  more  efificiently. 

It  has  been  said  that  the  steel  supports  are  not  ap,plicable  to  the 
treatment  of  the  ambulatory  class  of  patients,  such  as  is  seen  at 
hospital  clinics.  The  experience  at  the  Boston  Children's  Hospi- 
tal does  not  support  this  view.  Plaster  jackets,  which  were  formerly 
much  used  there,  are  being  discontinued  in  most  cases  in  favor  of 
the  more  adjustable  steel  appliances.  In  this  class  of  cases  it  has 
been  found  possible  to  secure  in  most  instances  the  intelligent  use 
of  the  antero-posterior  support.  The  chief  difificulty  is  to  obtain 
the  frequent  attendance  of  the  patients,  so  that  the  brace  may  be 
carefully  looked  after  and  made  to  fit  the  back.  The  plaster 
jacket  is,  however,  often  within  reach  in  practice  when  it  is  impos- 
sible to  obtain  a  brace.  It  is  an  efificient  apparatus,  moreover,  and 
gives  much  relief. 

In  this,  as  in  all  other  questions  of  surgical  methods,  much  de- 
pends upon  the  surgeon's  facility.  A  surgeon  whose  acquaintance 
with  surgical  appliances  is  simply  such  that  he  is  able  to  direct  his 
patient  to  an  instrument  maker  who  can  sell  the  most  marketable  in- 
strument, will  hardly  have  successful  results  from  mechanical  treat- 
ment. If  he  has  more  acquaintance  with  the  application  of  plaster 
corsets,  they  would  prove  preferable  in  his  hands.  A  slight  amount 
of  experience,  however,  will  be  sufificient  to  enable  him  to  familiar- 
ize himself  with  the  principles  of  thorough  mechanical  treatment 
by  proptr  appliances. 

The  circumstances  of  the  parents  will  often  determine  the  choice 
of  a  method  of  treatment,  inasmuch  as  they  may  be  unable  to  bear 
the  expense  of  even  a  cheaply  made  antero-posterior  support.  In 
these  cases  it  is  evident  that  one  must  use  plaster  of  Paris,  and  with 
plaster  of  Paris  a  perfectly  good  result  is  to  be  obtained. 

If  recumbency  is  necessary  in  such  cases,  a  cheap  oblong  bed- 
.  frame  can  be  made  out  of  light  gas-pipe  and  covered  with  cheap 
cloth,  and  the  expense  is  insignificant.  In  this  way  the  proper 
treatment  of  Pott's  disease  can  be  brought  within  the  reach  of  even 
the  poorest  of  families. 

The  choice-  of  the  proper  head  support  and  the  judgment  as  to 
when  a  support  is  needed  are  both  difficult  in  certain  cases. 

In  general,  when  the  disease  is  above  the  fourth  dorsal  vertebra, 
some  form  of  head  support  is  always  indicated,  and  often  in  cases 
when  the  disease  is  situated  a  little  lower  down,  as  at  the  sixth  or 
the  seventh  dorsal  vertebra,  some  head  support  is  usually  of  much 
benefit,  especially  if  the  deformity  is  a  large  one. 


roTT's  j)isi-:ASii. 


89 


The  so-called  jury-mast  is  efficient  as  a  cliin  and  head  su[Ji;ort, 
but  it  is  unsightly,  and  patients  are  anxious  to  be  freed  from  it  in 
upper  dorsal  disease,  earlier  than  is  desirable.  Less  unsightly  but 
more  dif^cult  to  adjust  is  the  Taylor  oval  ring.  This  latter  can  be 
made  a  most  efificient  appliance.  A  Thomas  collar  is  more  readily 
adjusted  and  is  cheap  ;  it  answers  admirably  in  cases  of  cervical 
disease.  When  there  is  a  tendency  to  throw  the  head  backward,  a 
high  rest  at  the  back  of  the  head  is  desirable.  If  the  opposite  ten- 
dency is  present,  a  wire  chin-rest, 
such  as  has  already  been  described, 
is  advisable. 

The  choice  of  treatment  in  a 
given  case,  the  need  of  recumbency 
during  the  severest  stages,  and  fix- 
ation in  a  recumbent  position  (which 
may  be  temporarily  necessary),  fol- 
lowed or  supplemented  by  the  ap- 
plication of  mechanical  supports — 
must  all  be  a  matter  of  judgment. 

When  recumbency  is  needed  it 
should  be  thorough,  and  this  is  not 
simply  done  by  placing  the  child 
in  bed.  No  superincumbent  weight 
should  be  allowed  to  fall  upon  the 
unprotected  spine,  and  the  appli- 
ance or  corset  should  be  worn 
night  and  day. 

Having  had  a  somewhat  ex- 
tended experience  in  the  treatment 
of  Pott's  disease  by  both  the  plaster  jacket  and  the  antero-posterior 
support,  the  writers  are  desirous  of  expressing  their  preference  for 
the  latter  in  all  cases  where  it  is  obtainable,  except  in  some  cases 
of  low  dorsal  caries  and  in  cases  with  a  serious  lateral  deviation  of 
the  column,  as  previously  explained.  In  saying  this,  they  do  not 
intend  in  any  way  to  throw  discredit  upon  the  plaster-jacket  treat- 
mnt,  which  is  a  very  efficient  one  and  only  suffers  by  comparison 
with  a  more  efificient  method  which  is  to  be  found  in  the  antero- 
posterior support. 


Fig.  113  — Plaster  Jacket  with  Jury-mast 
Applied. 


Treatment  of  Complications. 


Abscesses. — Lumbar  and  iliac  abscesses  constitute  a  most  formid- 
able complication  in  caries  of  the  spine,  even  more  so  perhaps  than 
psoas  abscesses,  as  the  possibilities  of  dangerous  rupture  are  greater, 


90 


OR  THOPEDIC  S  UR  GER  Y. 


and  the  future  course  more  uncertain.  They  present  a  mass  of 
tuberculous  matter,  which  either  remains  permanently  in  the  body, 
a  source  of  possible  future  tuberculous  infection,  or  they  extend, 
bursting  internally  or  through  the  skin,  in  the  latter  way  often  ex- 
posing the  patient  to  the  danger  of  septic  absorption  through  the 
imperfect  drainage  of  a  large  cavity. 

The  frequency  of  pelvic  abscess  is  shown  in  Michel's  figures.  Out 
of  forty-eight  cases  he  found  thirty-nine  in  the  pelvis  ("  Nouveau 
diet,  de  med.  and  chir.,"  and  Parker,  Brit.  Med.  Journal,  Jan.  12th, 
1884,  P-  78),  in  an  examination  of  eighty-two  dorsal  cases,  twenty- 
one  dorso-lumbar,  and  thirty-seven  lumbo-sacral  cases  of  caries  of 
spine,  he  found  that  there  were  abscesses  in  eight  per  cent  of  the  dor- 
sal cases,  thirty  per  cent  of  the  dorso-lumbar,  and  in  seventy  per 
cent  of  the  lumbo-sacral.  (See  also  Lachaniere,  Boston  Med.  and 
Surg.  Journal,  April  24th,  1884,  p.  397.)  This  may  fairly  illustrate 
the  fact  that  the  problem  of  the  treatment  of  iliac  abscess  is  one 
frequently  presented  to  us. 

Exactly  in  what  way  the  question  should  be  met  is  well  worthy 
of  discussion,  as  authorities  range  from  the  point  of  view  of  ex- 
treme expectancy  and  conservatism  to  that  of  early  and  radical 
operation. 

Treatment  of  the  spinal  column,  fixation,  and  relief  of  interver- 
tebral pressure  will  always  be  regarded  as  essential,  and  in  many 
cases  will  be  sufficient  to  promote  the  absorption  and  disappear- 
ance of  the  abscess.  Whether  this  takes  place  will  depend  in  all 
probability  on  the  amount  of  injury  that  has  been  done  to  the 
vertebrae  before  treatment  was  begun,  the  extent  of  the  lesion  of  the 
bone,  the  size  and  contents  of  the  abscesses,  whether  they  are 
chiefly  caseous  or  contain  bony  sequestra,  or  whether  the  propor- 
tion of  serous  fluid  is  large.  Even  if  absorption  does  not  immedi- 
ately take  place,  the  mass  may  become  encapsulated  and  be  appar- 
ently of  little  account  except  as  a  threat.  But  frequently,  as  is 
well  known,  such  abscesses  extend,  burst,  and  give  rise  to  much 
trouble. 

Expectancy  offers  a  thoroughly  recognized  method  of  treatment, 
well  sanctioned  by  authority,  and  backed  by  excellent  results  in 
many  cases.  One  of  the  most  noticeable  of  these  was  presented  by 
a  young  gentleman  of  twenty,  who  had  been  a  patient  of  Dr.  C.  F. 
Taylor,  of  New  York.  His  Pott's  disease  began  when  he  was  a  child 
of  three,  and  for  a  number  of  years  he  was  under  constant  treat- 
ment. At  the  time  that  the  writer  had  an  opportunity  to  examine 
him  he  was  twenty  years  of  age,  and  had  for  several  years  been  free 
from  any  symptoms  of  his  disease  and  was  apparently  entirely  well. 
He  had  been  without  a  support  for  the  spine  for  some  time.    There 


]\)TTS   J)  IS  EASE. 


91 


was  a  kyphotic  projection  in  the  middle  dfjrsal  region,  and  healed 
cicatrices  in  botii  groins — the  remains  (jf  five  successive  sinuses 
which  followed  double  iliac  abscesses.  He  was  in  good  flesh  and 
health.  The  abscesses  had  opened  themselves,  and  the  sinuses  had 
remained  open  for  years,  but  had  finally  closed  and  had  remained 
so  continuously  for  a  long  time. 

Abscesses  may,  however,  be  absorbed  even  after  they  have  pre- 
sented the  signs  of  fluctuation  and  have  appeared  as  distinct  swell- 
ings, as  in  the  following  case  seen  by  the  writers. 

A  boy  of  five  presented  Pott's  disease  in  the  lower  dorsal  verte- 
bras and  a  fluctuating  swelling  in  the  right  groin,  with  the  charac- 
teristics and  accompanying  symptoms  of  iliac  abscess  of  a  small 
size.  It  was  decided  by  the  mother  not  to  undertake  any  treat- 
ment, and  he  was  not  seen  until  four  years  later.  According  to 
the  mother's  statement,  the  swelling  in  the  groin  increased  grad- 
ually and  descended  down  the  thigh,  but  finally  grew  smaller  and 
disappeared.  At  the  time  of  the  second  examination  the  boy 
presented  the  usual  appearance  of  a  patient  who  had  recovered 
from  a  case  of  Pott's  disease :  i.e.,  a  rounded  kyphotic  projection 
and  small  stature.     No  trace  of  an  abscess  could  be  found. 

It  cannot,  however,  be  inferred  that  absorption  or  encysting  of 
a  large  abscess  is  the  rule,  either  with  or  without  treatment.  Cases 
hke  the  following  are  unfortunately  not  exceptional:  J.,  a  girl  aged 
sixteen,  of  good  flesh  and  apparent  health,  but  Avith  a  distorted  hip, 
from  a  hip  disease  of  early  childhood,  presented  signs  of  lower 
spinal  caries,  and  developed  a  left  inguinal  abscess,  which  after- 
ward became  a  psoas  abscess,  and  finally  burst,  giving  rise  to  hectic 
and  eventually  death  from  septicaemia  and  exhaustion. 

In  how  many  cases  expectant  treatment  may  be  relied  upon  as 
safe  and  in  how  many  the  result  is  disastrous,  it  is  impossible  to 
state,  as  statistics,  are  wanting.  We  may,  however,  accept  the 
statement  of  Treves,  that  the  most  frequent  cause  of  death  in  Pott's 
disease  is  from  abscess  and  its  sequelae.  (See  "  International  Ency- 
clopaedia of  Surgery,"  art.  Pott's  Disease.)  In  fine,  it  will  be 
readily  admitted  that  the  treatment  of  abscess  by  expectation  has 
its  limits. 

The  methods  of  treatment,  apart  from  that  of  expectancy,  are : 

1.  That  of  repeated  aspiration. 

2.  That  of  injection  of  fluid  to  promote  absorption. 

3.  That  of  incision. 

The  former  wall  be  found  to  be  unsatisfactory  in  many  cases,  for 
the  reason  that  the  aspiration  does  not  remove  the  caseous  clots, 
but   only  the  serous  and  sero-purulent  fluid — the  least  dangerous 


92 


ORTHOPEDIC  SURGERY. 


part  of  the  contents  of  the  abscess,  and  that  easily  renewed  by 
subsequent  effusion. 

It  is  probable  that  aspiration  favors  absorption.  Repeated  as- 
piration, in  weakening  the  wall  of  the  abscess  at  one  point,  favors 
pointing  and  discharge  where  absorption  does  not  take  place. 

In  regard  to  the  question  of  the  cure  of  an  abscess  by  the  injec- 
tion of  fluid,  there  is  but  little  as  yet  definitely  known  in  cases  of 
large  abdominal  abscesses,  as  the  method  has  been  in  use  but  a 
comparatively  short  time. 

Hyperdistention  with  carbolic-acid  solution,  proposed  by  Mr.  Cal- 
lender,  is  dangerous  from  the  possibility  of  carbolic-acid  poisoning. 

The  writer  recorded  a  death  in  a  boy  of  five  after  washing  a 
small  cold  abscess  from  hip  disease  with  a  few  ounces  of  one  to 
forty  solution  of  carbolic  acid.  {Bost.  Med.  Journal,  1880,  Vol. 
VII.,  p.  578;  Frankel,  Wien.  Mediz.  Woch.,  1884,  p.  34;  Vincent, 
Med.  Press,  aud  Circ,  1887,  Vol.  XXIV.,  p.  529.) 

Whether  iodoform  or  corrosive  sublimate  or  sulphurous  acid  can 
be  used  w^ith  safety,  is  not  yet  decided.  If,  however,  there  is  dan- 
ger, in  all  probability  in  iliac  and  lumbar  abscesses  it  will  be  at  its 
greatest,  owing  to  the  sinuous  channel  and  pockets  of  these  ab- 
scesses, and  the  liability  of  retention  of  a  larger  quantity  of  injected 
fluid  than  was  intended. 

The  question  of  incision  would  theoretically  be  easily  answered. 
An  abscess  is  an  abscess  wherever  it  is  situated — a  source  of  dan- 
ger to  the  patient.  When  it  is  not  absorbed,  it  should  be  incised 
and  the  contents  evacuated. 

In  opposition  to  this  aphorism  we  have  the  teachings  of  the 
older  surgeons,  which  come  to  us  as  a  tradition,  that  large  cold 
abscesses  are  to  be  left  to  nature;  the  manifest  dread  most  sur- 
geons seem  to  have  in  opening  a  large  pus  cavity ;  and  the  fact 
that  experience  in  many  cases  of  incision  would  show  that  opening 
the  abscess  would  sometimes  appear  to  be  injurious  and  in  fact  to 
hasten  death.  This  dread  has  been  materially  diminished  since  the 
introduction  of  antiseptic  surgery,  but  even  under  careful  precau- 
tion it  is  difficult  to  guard  for  months  against  possible  sepsis.  And 
in  many  of  these  cases  of  lumbar  and  iliac  abscess  it  is  impossible 
to  obtain  primary  intention,  as  it  is  impossible  to  reach  the  origi- 
nal focus  of  disease. 

Cold  abscesses  from  caries  of  spine  differ  from  cold  abscesses 
elsewhere  in  this,  that,  to  reach  the  surface  of  the  body,  the  chan- 
nel is  long  and  often  tortuous.  It  follows  from  this  that  the  exter- 
nal appearance  of  the  abscess  may  give  no  indications  of  the  state 
of  the  original  disease,  or  of  the  existence  or  non-existence  of  sacs 
along  the   course  of  the   channel  leading  to  the  original  caseous. 


POTT'S   J  )I  SKA  si:.  93 

lesion  of  the  spine.  These  sacs  may  be  entirely  separaterl  by 
layers  of  fascize,  except  perhaps  through  a  small  opening  found 
with  difficulty  at  the  time  of  operation;  and  in  evacuating  one  the 
other  may  be  imperfectly  drained. 

In  certain  cases,  therefore,  the  incision  of  the  abscess  at  the 
surface  is  not  followed  by  relief,  and  may  be  the  prelude  to  the 
patient's  decline  and  death.  In  many  cases  where  the  abscess  is 
quite  thoroughly  localized,  the  incision  is  little  more  than  the 
lancing  of  a  boil.  The  abscess  has  worked  its  way  thoroughly  to 
the  surface,  and  the  channel  connecting  the  abscess  with  the  spine 
is  closed  or  nearly  closed,  and  the  original  point  of  disease  in  the 
vertebra  is  in  a  quiescent  stage. 

The  matter  is  an  entirely  different  one  when  we  are  dealing  with 
large  abscesses  projecting  into  the  abdominal  cavity,  and  which 
may  be  termed  abdominal  abscesses.  These  may  not  differ  in  ap- 
pearance, under  inspection  or  on  palpation,  from  perityphlitic  ab- 
scesses or  other  collections  of  pus  underneath  the  peritoneum  and 
pressing  into  the  peritoneal  cavity. 

A  certain  number  of  these  abscesses  remain  encysted,  and  occa- 
sion no  trouble.  Others  end  in  a  spontaneous  rupture,  bursting  in 
various  directions.  The  overflow  comes  to  the  surface  of  the  skin 
or  intestine,  discharges,  and  leaves  a  sinus,  which  may  heal,  per- 
haps, or  remain  with  a  slight  discharge.  The  main  body  of  the 
abscess  has  meanwhile  discharged  its  overflow  in  another  direction, 
leaving  another  sinus,  and  so  seteral  sinuses  are  formed.  In  some 
instances,  following  the  abscess  in  one  groin,  a  second  may  appear 
in  the  other, — two  outlets  from  the  central  abscess  around  the  dis- 
eased vertebral  bodies.  The  spontaneous  rupture  into  the  rectum 
or  intestine  is  not  often  the  occasion  of  any  disturbance;  and  in 
some  instances  the  abscesses  have  entirely  evacuated  themselves  in 
this  way,  and  given  rise  to  no  further  disturbance. 

The  records  of  the  autopsy-room,  however,  show  that  so  fortu- 
nate a  termination  is  by  no  means  the  rule,  but  it  is  easy  to  see 
that  the  termination  of  the  case  is  largely  iniluenced  by  the  size 
and  character  of  the  abscess  which  is  present. 

As  it  will  be  readily  admitted  that  in  certain  severe  cases  treat- 
ment by  expectancy  in  large  abdominal  abscesses  is  followed  by 
disastrous  results,  there  is  no  need  of  argument  in  favor  of  pre- 
ventive measures,  if  any  may  be  regarded  as  effective  and  safe. 

Free  radical  incisions  have  been  advocated  by  Konig,  Treves, 
Andrews,  and  others,  and  in  many  cases  are  strongly  indicated  on 
account  of  the  serious  symptoms  which  the  abscess  may  set  up  by 
the  effects  of  its  pressure. 

Lacharriere  has  collected  twenty-eight  cases  treated  by  antisep- 


94 


ORTHOPEDIC  SURGERY. 


tic  incision  dressed  with  strict  antiseptic  precautions.  Of  these 
five  died,  fourteen  were  healed  without  sinuses,  and  in  nine  the 
result  was  uncertain.  Twenty-one  cases  were  treated  by  curetting 
the  abscess  ^alls,  and  of  these  two  died,  fourteen  were  healed,  and 
in  five  sinuses  were  left.  This  latter  procedure  is  not  possible  ex- 
cept in  abscesses  of  the  lumbar  region  and  of  the  back.  In  psoas 
or  iliac  abscess  such  a  treatment  is  not  only  not  always  possible 
but  in  certain  cases  dangerous. 

If  an  operation  is  done  with  proper  precautions  it  is  attended 
with  no  risk  of  sepsis.  It  is  not  to  be  expected,  however, 
that  simple  incision  and  drainage  will  close  the  abscess  in  most 
cases.  On  the  contrary,  their  tendency  is  to  discharge  almost  in- 
definitely, and  this  must  be  borne  in  mind  in  advocating  operation 
where  it  is  not  urgently  indicated  by  pressure  effects  and  the  dis- 
tention of  the  abscess. 

Very  often  an  abscess  which  has  advanced  so  far  as  to  appear  as 
a  swelling  in  the  groin  may  be  opened  in  the  back  and  no  second 
opening  may  be  necessary.  An  incision  is  made  along  the  side  of 
the  lumbar  vertebrse  just  outside  the  transverse  processes  and 
carried  down  through  the  quadratus  lumborum  muscle  until  the 
abscess  sac  is  reached.  It  can  usually  be  distinguished  without 
difficulty  and  is  made  tense  by  pressure  in  the  groin.  It  is  evacu- 
ated by  an  incision  at  the  bottom  of  this  wound  and  perfect  drain- 
age is  secured. 

In  opening  the  abscess  in  this  way  at  the  seat  of  the  disease  it 
may  be  possible  with  a  curette  to  remove  a  part  of  the  diseased 
body  of  the  vertebrse.  This,  however,  must  be  done  with  very 
great  care.     To  be  of  any  use  it  must  be  thorough. 

A  retro-pharyngeal  abscess  is  best  opened  by  passing  into  the 
mouth  a  bistoury  wound  to  within  half  an  inch  of  its  point  with 
cotton,  and  cutting  freely,  using  the  finger  as  a  guide.  The  child 
should  be  held  face  downward  in  order  that  the  pus  may  not  enter 
the  trachea,  and  plenty  of  swabs  should  be  at  hand  to  keep  the 
mouth  clear,  for  the  gush  of  pus  is  sometimes  considerable. 

When  the  abscess  bursts. into  the  lungs  or  the  intestines,  there 
is  nothing  to  be  done  beyond  the  usual  expectant  treatment. 

Treatment  of  Psoas  Contraction. — When  flexion  of  one  or  both 
thighs  has  come  on,  it  is  not  likely  to  diminish  spontaneously,  and 
if  the  deformity  is  allowed  to  go  untreated,  such  contractions  are 
formed  that  the  condition  may  become  permanent. 

A  permanent  contraction  of  one  or  both  psoas  muscles  with  the 
thigh  flexed  is  a  serious  deformity.  If  it  exists  on  both  sides,  the 
patient  can  walk  only  with  the  trunk  held  nearly  horizontal.  If  it 
is  unilateral,  it  leads  to  a  very  serious  disability,  requiring  in  most 


j'OTTS  j)isi-:asI':.  c/y 

cases  the  use  of  a  crutch,  for  the  spine  cannot  be  flexed  to  allow 
the  foot  to  reach  the  ^n'ound  in  walkin^^  as  it  docs  when  right- 
angled  flexion  of  the  thigh  exists  as  a  result  of  hip  disease.  For 
these  reasons  it  is  desirable  to  attack  psoas  contraction  with  very 
vigorous  measures,  which  afford  a  prospect  of  averting  any  perma- 
nent contraction. 

In  the  early  stages  the  child  should  be  put  to  bed  on  a  frame. 
A  light  extension  should  be  applied  to  the  leg,  and  the  jjulley 
should  be  gradually  lowered  until  the  leg  is  straight  and  the  flexion 
gone.  In  cases  where  the  flexion  has  only  existed  a  few  weeks  or 
months,  this  is  generally  easily  accomplished  in  one  or  two  weeks. 
If  not,  or  if  a  more  rapid  method  is  desired  in  the  first  instance, 
the  child  should  be  anaesthetized  and  the  leg  straightened  by  force 
and  retained  by  plaster  of  Paris  or  some  retentive  apparatus.  If 
this  cannot  be  done  with  the  use  of  moderate  force,  it  is  better  to 
divide  and  cut  the  fascia  and  the  contracted  bands — an  operation 
which  cannot  often  be  done  thoroughly  subcutaneously,  for  there 
are  many  deep  bands. 

The  deformity  is  almost  sure  to  return  if  the  patients  are  allowed 
to  go  about,  and  they  should  either  be  kept  on  a  frame,  or  an  arm 
should  be  extended  down  from  the  brace  or  the  jacket  to  keep  the 
thigh  fully  extended.  Finally,  subtrochanteric  osteotomy  may  be 
necessary  in  severe  cases,  but  it  should  not  be  applied  until  after 
recovery  from  caries. 

Paralysis. — ^The  treatment  of  paralysis  is  at  present  chiefly  expec- 
tant. Medication  is  that  employed  in  meningitis  and  compressive 
myelitis.  Ergot,  iodide  of  potash,  bromide  of  potash,  strychnia, 
physostigma,  have  been  used  and  recommended;  local  application 
of  blisters,  cautery,  ice,  hot  water,  have  been  recommended,  and 
the  use  of  the  cautery  is  especially  advised  by  neurologists. 

The  natural  course  of  the  paralysis  is  toward  recovery,  and  in 
many  cases  this  comes  unexpectedly;  so  that  a  careful  estimate  of 
the  effects  of  different  agents  is  difficult.  Recovery  takes  place  in 
a  large  majority  of  cases  under  any  treatment,  but  it  is  hastened 
and  made  almost  sure  by  the  early  adoption  of  efficient  mechanical 
measures. 

The  actual  cautery  is  a  tradition  of  the  neurologist,  based  on 
theoretical  grounds  and  founded  on  improvement  noticed  in  a  few 
cases.  In  view  of  the  very  satisfactory  results  obtained  without 
the  use  of  the  cautery,  so  barbarous  a  means  should  not  be  em- 
ployed, unless  supported  by  stronger  claims  than  can  at  present  be 
urged. 

It  is,  however,  best  to  put  the  patient  at  once  upon  his  back,  as 
in  this  way  the  full  development  of  the  paralysis  may  be  prevented 


g6  ORTHOPEDIC  SURGERY. 

and  its  course  shortened.  Gibney '  and  others  recommend  iodide  of 
potash  in  large  doses  for  the  treatment  of  this  form  of  paralysis, 
but  the  writers  have  not  seen  any  noticeable  benefit  from  its  use. 
Recumbency  and  extension  by  weight  seems  at  times  to  hasten 
recovery. 

Operative  Treatment  of  Potfs  Disease. — It  is  only  within  a  few 
years  that  the  possibility  of  direct  surgical  interference  in  Pott's 
disease  has  been  considered.  Israel/  in  1882,  in  opening  an  ab- 
scess in  the  lumbar  region  of  a  patient  thirty-four  years  old,  with 
scoliosis  persisting  since  boyhood  and  suddenly  accompanied  by 
paralysis,  found  extensive  disease  of  the  bone.  He  resected  a 
diseased  portion  of  the  twelfth  rib,  and  scraped  out  the  carious 
portion  of  the  diseased  vertebral  body,  penetrating  into  the  verte- 
bral canal,  from  which  a  quantity  of  pus  discharged.  The  patient 
did  well  for  five  weeks,  when  an  empyema  resulted  and  death  fol- 
lowed.    The  operative  interference  had  no  effect  upon  the  paralysis. 

Some  years  ago  Mr.  Treves  read  a  paper  advocating  direct  inci- 
sion in  cases  of  lumbar  caries  and  in  certain  cases  of  dorsal  caries 
where  collections  of  pus  have  formed.  A  vertical  incision  is  made 
near  the  outer  edge  of  the  erector  spinae  muscle ;  the  sheaths  of 
that  muscle  and  of  the  quadratus  lumborum  are  cut  through;  the 
psoas  muscle  itself  is  incised  and  the  vertebrae  are  reached  by  con- 
tinuing the  operation  along  the  deep  aspect  of  that  muscle.  The 
vertebrae  can  then  be  inspected  and  any  diseased  bone  removed. 
Treves  3  reported  three  operations,  after  all  of  which  the  patients 
made  a  good  recovery. 

Since  then  the  field  of  operation  has  been  somewhat  extended. 
Podres"  cut  down  upon  the  vertebral  column  in  a  case  of  cervical 
caries  Avhere  there  was  evidence  of  a  deep  collection  of  pus.  He 
made  an  incision  of  two  inches  along  the  posterior  border  of  the 
sterno-mastoid  muscle  and  then  with  a  blunt  instrument  followed 
up  the  brachial  plexus  until  he  reached  the  vertebral  column.  The 
sixth  and  seventh  cervical  vertebrae  were  found  superficially  ulcer- 
ated. The  abscess  was  curetted  and  the  wound  dressed  aseptically. 
A  sinus  remained  for  six  months  and  the  vertebrae  had  to  be 
curetted  again;  after  that  the  wound  healed. 

Boeckel,  Reclus,  Ashhurst  and  others  have  since  practised  the 
plan  of  cutting  down  on  to  the  diseased  vertebrae  and  removing  as 
far  as  possible  the  carious  bone  with  a  gouge  or  Volkmann's  spoon. 
As  a  rule  the  results  of  the  operation  have  not  been  successful,  the 

*  Medical  Record,  October  24th,  1S85,  p.  453. 
=  Berliner  klin.  Woch.,  1882,  No.  10. 

3  S.  Treves,  Brit.  Med.  Journ.,  Jan.  12th,  1884. 

4  Podres,  Cent.  f.  Chir.,  No.  38,  1886. 


rOTT'S   J)  IS  EASE.  97 

benefit  in  most  cases  bcinj^  only  tcmpcjrary  and  tlie  outcome  nrjt 
uncommonly  fatal.  Practically  the  bodies  of  the  vertebrae  are  very 
hard  to  reach  except  in  the  lumbar  region,  and  when  once  reached 
the  accurate  and  thorough  removal  of  the  diseased  tissue  is  a  prob- 
lem of  much  difficulty. 

Removal  of  the  Lmnincc  for  the  Relief  of  Pressure  Paralysis. — 
The  operation  of  laminectomy,  or  trephining  of  the  spine,  is  one 
which  to-day  excites  much  interest.  It  is  undertaken  for  the  relief 
of  pressure  upon  the  cord,  and  although  it  is  still  in  its  early  in- 
fancy, it  is  an  operation  which  seems  likely  to  come  more  widely 
into  vogue,  temporarily  at  least,  so  that  it  is  worth  while  to  inquire 
somewhat  carefully  into  the  present  status  of  the  operation.  The 
excellent  articles  of  Dr.  Willard  '  and  Dr.  J.  W.  White  ^  on  the  sub- 
ject have  been  largely  drawn  upon  by  the  writers  in  presenting  the 
subject. 

The  tolerance  of  animals  to  operations  upon  the  spinal  column 
was  shown  by  the  experiments  of  Maydl,^  who  found  that  it  was 
possible  to  cut  down  upon  the  cord,  suture  the  dura,  and  even 
resect  the  cord  without  killing  many  of  the  animals.  He  was  led 
by  these  experiments  to  operate  successfully  upon  a  case  of  trau- 
matic Pott's  disease  in  a  man  twenty-six  years  old.  In  this  case  he 
removed  the  arches  of  the  ninth,  tenth,  and  eleventh  vertebrae  and 
thus  relieved  the  pressure  upon  the  cord. 

To  Macewen  undoubtedly  belongs  the  credit  of  resuscitating  the 
operation  of  systematically  searching  for  and  removing  any  exist- 
ing lesion,  although  from  the  time  of  ^Egineta,  Bell,  and  Cooper  it 
has  been  discussed.  Only  a  few  years  since  it  was  denounced  as 
unjustifiable.'*  Macewen  justly  claims  that  he  has  demonstrated 
that  "  the  spinal  membranes  and  the  cord  itself  can  be  exposed, 
and  that  neoplasms  and  encroachments  upon  the  lumen  of  the 
canal  may  be  removed  therefrom  without  unduly  hazarding  life. 
The  old  objections  that  such  operations  were  full  of  danger  from 
hemorrhage  and  were  unprofitable  and  unsuccessful,  have  certainly 
been  thoroughly  disproven,  and  we  are  now  able  to  offer  a  measure 
of  success  to  a  class  of  hitherto  hopeless  cases."  = 

The  operation  consists  in  cutting  down  upon  the  spinous  pro- 
cesses in  the  region  of  the  deformity,  the  incision  being  slightly  to 
one  side  of  the  centre,  so  that  the  resulting  cicatrix  will  not  be 
unduly  pressed  upon  during  recumbency.  All  the  soft  tissues  are 
then  stripped  bare  with  a  periosteal  knife,  until  the  entire  lamina  is 
exposed.     One-half  or  the  whole  of  the  arch  may  be  removed  as 

'  De  F.  Willard,  Trans,  of  Coll.  of  Phys.  of  Phila.,  March  6th,  1SS9. 
"  Annals  of  Surgery,  July,  1889.  3  Wiener  Med.  Presse,  1S84.,  42. 

't  Ashhurst's  "  Encycl.  Surgery,"  vol.  iv.  s  British  I\Ied.  Journ.,  Auo-.  nth    iSSS. 

7 


g8  ORTHOPEDIC  SURGERY. 

necessary,  but  even  an  opening  upon  one  s>ide  gives  ready  access  to 
the  canal.  A  half  trephine,  a  saw  with  cutting  edge  upon  its  convex 
surface,  a  chisel,  or  a  pair  of  angular  cutting  bone  forceps  or  rongeur 
forceps  may  be  used  for  making  the  section.  When  cut  through 
the  lamina  can  be  lifted  off,  and  then  the .  theca  lies  exposed. 
Sometimes  the  cord  can  be  seen  pulsating  in  its  bony  canal;  again, 
it  lies  shrunken. 

If  the  pressure  has  been  due  to  an  inflammatory  growth,  the 
connective-tissue  neoplasm  may  be  dissected  away  with  scissors 
from  the  theca,  or  the  latter  may  require  removal  with  the  growth. 
Should  the  pressure  have  been  due  to  bony  growths,  the  ossific 
material  will  probably  lie  in  front  of  the  cord  and  should  be 
searched  for  as  far  as  safety  permits,  the  cord  being  lifted  with  a 
blunt  hook.  All  discovered  portions  of  dead  bone  should  be  re- 
moved, and  thorough  drainage  secured  laterally,  if  possible.  Even 
when  the  anterior  bony  projection  can  be  neither  discovered  nor 
removed,  the  pressure  upon  the  cord  will  be  very  greatly  relieved, 
by  the  freedom  allowed  to  it  for  expansion  posteriorly.  Much  of 
the  benefit  derived  from  the  operation  is  doubtless  due  solely  to 
this  relief  of  pressure.  Erosion  of  diseased  bone  should  be  prac- 
tised, if  possible,  and  the  most  thorough  antiseptic  precautions 
during  operation  and  in  subsequent  dressings  observed.  The  su- 
perficial tissues  should  be  sutured  separately  from  the  deeper  ones. 
Hemorrhage  may  be  controlled  by  pressure  forceps,  by  ligation, 
or  by  packing  with  iodoform  gauze.  Immediate  improvement  is 
not  to  be  expected. 

In  one  of  Macewen's  cases  motion  was  first  noticed  on  the  eighth 
day,  in  another  it  returned  much  more  slowly. 

Macewen  operated  May  9th,  1883,  on  a  case  of  sensory  and  motor 
paralysis  with  incontinence  of  urine  and  feces,  removing  three 
laminae.  The  patient  made  a  brilliant  recovery.  His  series  of 
cases  includes  four  others,  two  of  which  were  successful. 

Horsley  has  operated  on  a  large  number  of  patients  already,  but 
only  reports  one  case  as  yet  where  shortly  after  operation  the 
paralysis  was  disappearing. 

Abbe '  reported  a  case  of  extra-dural  tumor  of  the  spine  (which 
White  interpreted  as  a  case  of  Pott's  disease)  where  slight  improve- 
ment followed  operation. 

Mr.  Wright^  has  recently  attacked  a  case  of  dorsal  Pott's  disease 
by  this  operation,  in  the  hope  of  relieving  a  severe  and  progressive 
paralysis.  The  disease  was  in  the  mid-dorsal  region  and  an  incision 
was    made    over    the  spines  along  the  angular  prominence.     The 

^  Medical  Record,  February  gth,  1889.  =  Wright,  Lancet,  July  14th,  1888,  64. 


POTTS  DISEASE. 


99 


laminae  on  each  side  were  divided  and  with  their  spinous  processes 
were  removed,  exposing  the  cord,  which  was  found  surrounded  by 
a  buff-colored,  tough,  leathery  substance.  This  was  cut  away  with 
scissors  and  the  muscles  and  skin  brought  together  over  the  wound. 
Healing  took  place  by  first  intention  and  slight  temporary  im- 
provement followed,  but  the  patient  soon  fell  back  to  the  same 
condition  in  which  he  was  before  operation,  and  this  condition 
persisted. 

The  most  recent  and  one  of  the  most  successful  operations  upon 
the  diseased  vertebrae  is  the  one  reported  by  Lane  [Brit.  Med. 
/ourna/,  April  20th,  1889)  in  which  a  paralysis  from  mid-dorsal  curv- 
ature improved  perceptibly  within  four  days  of  the  time  of  resec- 
tion of  the  laminae,  and  in  a  month  the  boy  was  moving  his  legs 
freely  and  had  improved  very  much  in  his  general  condition.  At 
the  time  of  operation  the  boy  was  seven  and  one-half  years  old  and 
had  had  the  curvature  between  one  and  two.  years,  and  the  paraly- 
sis for  several  months. 

Duncan  reported  in  May,  1889  {Edin.  Mcd.Jo7irnaL),7i.  case  where 
paraplegia  which  had  existed  a  year  was  cured  by  the  removal  of 
the  laminae  of  the  fourth,  fifth,  sixth,  and  seventh  vertebrae. 

Dr.  H.  L.  Burrell,  of  Boston,  recently  reported  to  the  American 
Orthopedic  Association  an  operation  done  for  the  relief  of  paraly- 
sis in  a  case  of  advanced  dorsal  caries.  The  patient  was  in  a  very 
bad  general  condition  before  operation  and  died  soon  afterward. 

Considering  then  the  published  cases,  there  are  eleven  operations 
on  record  as  follows: 

Macewen,  five,  three  successful;  Horsley,  one  reported,  doubt- 
ful; Abbe,  one,  slight  improvement;  Wright,  one,  no  permanent 
improvement;  Lane,  one,  successful;  White,  one,  fatal;  Duncan, 
one,  fatal;  Burrell,  H.  L.,  one,  fatal.' 

That  is  of  twelve  operations  on  record,  four  have  been  success- 
ful. Mr.  Horsley's  unreported  cases  are  said  to  have  been  more 
favorable. 

Of  the  successful  cases,  in  one  case  paralysis  had  existed  for  two 
years  and  involved  both  motion  and  sensation,  and  the  sphincters 
of  the  bladder  and  rectum  were  affected,  while  spastic  contractures 
of  the  muscles  were  present.  In  this  case  recovery  Avas  so  good 
that  five  years  later  the  patient  was  able  to  play  football.  In  the 
second  and  third  cases  sensation  and  motion  were  both  lost  at  the 
time  of  operation  and  the  sphincters  wxre  involved.  The  fourth 
case  is  that  of  Mr.  Arbuthnot  Lane  already  related  in  full. 

'  British  Med.  Journ.,  August  nth,  iSSS,  ii.,  30S,  323;  Glasgow  Med.  Tourn.,  1SS4, 
xxii.,  65  ;  Glasgow  Med.  Journ.,  1886,  xxv.,  210;  Med.  Contemp.  Napoli,  1SS4.  i.,  520; 
Lancet,  July  14th,  1888,  264;  Internal.  Journ.  Surgery  and  Antiseptics,  October,  iSSS, 
225  ;  Brit.  Med.  Journal,  April  20th,  iSSg. 


lOo  ORTHOPEDIC  SURGERY. 

Of  Mr.  Lane's  case  it  may  be  said,  however,  that,  in  view  of  the 
usual  clinical  history  of  pressure  paralysis  from  caries  it  is  possible 
that  speedy  recovery  would  have  taken  place  without  operation ; 
and  this  criticism  may  perhaps  be  made  of  some  of  the  other  suc- 
cessful cases.  Once  more  it  may  be  allowable  to  call  attention  to 
the  fact  that  in  the  cases  of  paralysis  studied  by  Taylor  and  Lovett 
the  recovery  percentage  was  lOO  when  the  paralysis  came  on  under 
treatment,  and  that  it  is  very  favorable ;  in  any  event  more  than 
83^  of  all  the  cases  recover  under  conservative  treatment. 

Operations  for  the  relief  of  traumatic  perssure  upon  the  cord 
have  been  collected  and  arranged  by  Ashhurst  ("  International 
Encyc.  of  Surg.,"  2d  Ed.,  Vol.  IV.) 

The  objections  to  the  operation  are  stated  by  Willard  as  follows: 
"  I.  It  endangers  life,  and  a  certain  percentage  of  cases  will  die 
from  shock  that  would  otherwise  live  for  years  and  might  even 
recover. 

"  2.  It  is  uncertain  in  its  relief,  since  when  the  compression  is  an- 
terior it  may  be  impossible  to  remove  the  cause. 

"  3.  It  weakens  the  only  support  of  the  head  and  shoulders,  in  the 
portion  of  the  column  upon  which  alone  dependence  is  to  be 
placed,  since  the  anterior  support — i.e.,  the  bodies  of  the  vertebrae 
— has  been  already  disintegrated. 

"  This  weakening  process  must  throw  additional  strain  upon  both 
muscles  and  diseased  bone,  and  the  operation,  if  done  before  de- 
cided consolidation  had  occurred,  would  leave  the  trunk  without 
any  support,  thus  increasing  the  risk  of  sharp  flexion  and  deformity." 
It  may  be  said,  therefore,  that  resection  of  the  laminae  of  the 
vertebral  column  is  an  operation  which  is  attended  with  some  risk 
of  a  fatal  issue — a  risk  which  cannot  yet  be  stated  numerically. 
But  that  at  the  same  time  several  brilliant  successes  have  followed 
the  operation,  so  that  it  holds  out  the  hope  of  relieving  cases  of 
paraplegia  which  would  otherwise  have  been  hopeless.  The  ope- 
ration, however,  has  no  place  in  the  treatment  of  Pott's  disease  until 
the  conservative  measures  have  been  faithfully  tried  over  a  sufifi- 
cient  period  of  time — measures  which  in  most  cases  will  prove 
efficient  and  successful  in  the  relief  of  the  paralysis. 

Constitutional  Treatment. — Means  for  improving  the  patient's  gen- 
eral condition  are  important,  and  are  such  as  are  em.ployed  in 
patients  with  the  tuberculous  state  elsewhere  in  the  body:  Care  as 
to  diet,  proper  nutritious  food,  tonics,  and  digestives,  and  such 
medicines  as  are  regarded  as  reconstructive  (cod-liver  oil,  the  hypo- 
phosphites  of  lime,  and  soda,  iron,  quinine,  etc.).  As  in  all  chronic 
diseases,  medication  should  vary  with  the  patient's  condition.  The 
patient   should   be   weighed   from   time   to   time   and    an   estimate 


POTT'S  J)  I  SEAS  E.  ^       lOI 

formed  as  to  whether  his  condition  needs  fattening  or  restricted 
diet,  and  whether  the  amount  of  exercise  allowed  should  be  in- 
creased or  diminished. 

Exercise  and  fresh  air,  the  best  of  tonics,  are  to  be  directed  in 
such  cases,  and  to  such  an  amount  as  the  acuteness  of  the  symp- 
toms, and  the  danger  of  access  of  disease  by  possible  falls  and  jars 
permit.  It  should  be  borne  in  mind  that  no  appliance  can  be  used 
which  will  be  so  thorough  a  means  of  fixation  that  injury  may  not 
follow  violent  falls,  and  also  that,  to  favor  the  reconstructive  pro- 
cess essential  to  the  arrest  of  caries,  a  certain  amount  of  exercise, 
sunshine,  and  freedom  from  the  imprisonment  of  the  sick-room,  are 
of  the  greatest  advantage.  Judgment  as  to  the  relative  importance 
of  these  different  dangers  constitutes  the  treatment  of  the  disease. 

Summary. — The  proper  treatrrient  of  caries  of  the  spine  is  not 
the  application  of  any  method,  the  use  of  any  corset  or  brace,  but 
the  employment  of  such  means  as  are  most  efficient  for  carrying 
out  the  object  aimed  at.  A  brace  is  useless  in  the  case  of  persons 
unable  to  adjust  it,  a  plaster  jacket  applied  about  the  trunk  is  use- 
less and  brutal  surgery  in  disease  of  the  cervical  or  high  dorsal 
region.  Recumbency,  carried  to  a  point  of  depressing  the  patient's 
mental  and  physical  condition,  is  as  much  of  a  mistake  as  to  drag 
a  pati'ent  about  who  is  anxious  to  lie  down. 

In  the  treatment  of  these  cases,  the  surgeon  should  be  familiar 
with  the  advantages  to  be  gained  by  all  methods,  and  should  em- 
ploy each  as  the  case  may  demand,  and  for  such  a  length  of  time 
as  the  circumstances  of  the  case  may  require,  or  combine  the  dif- 
ferent methods  as  may  be  advisable. 

In  a  general  way  he  may  formulate  to  himself  that :  In  acute, 
painful  cases  absolute  recumbency  with  fixation,  combined  with 
extension  in  disease  of  the  upper  part  of  the  column,  is  the  best 
method  until  the  active  stage  of  the  disease  is  passed ;  in  middle 
and  lower  dorsal  caries  an  immovable  plaster  jacket,  without  head 
attachment,  in  the  case  of  negligent  people. 

In  disease  of  the  cervical,  dorsal,  and  upper  lumbar  regions 
some  mechanical  appliances  must  be  used  if  the  patient  is  not 
recumbent.  The  choice  will  be  directed  by  the  circumstances  of 
the  case  (amount  of  care,  expense,  sensitiveness  as  to  appearance) 
between  a  plaster  bandage  (holding  neck  and  trunk),  collars, 
braces,  etc. 

In  the  lowest  lumbar  region  recumbency,  with  or  without  fixa- 
tion by  extension,  constitutes  the  most  thorough  method  of  treat- 
ment. Braces  or  corsets  are  of  value  as  a  help  for  fixation  during 
recumbency  or  in  the  stages  of  convalescence,  and  where  recum- 
bency is  unadvisable. 


102  ORTHOPEDIC  SURGERY. 

Properly  constructed  braces,  designed  so  as  to  apply  thorough 
antero-posterior  support,  with  fixation  in  an  improved  position, 
form  a  method  of  treatment  most  satisfactory  to  the  surgeon  capa- 
ble of  controlling  and  inspecting  his  patient.  For  such  treatment, 
however,  care  on  the  part  of  the  attendant  of  the  patient,  and 
ready  facilities  for  the  adjustment  of  braces,  are  necessary. 

Whether  recumbency  for  a  time  is  required,  or  whether  ambula- 
tory treatment  with  fixation  appliances  is  sufficient,  are  questions 
of  judgment  in  individual  cases. 


CHAPTER    II. 
LATERAL   CURVATURES   OF   THE   SPINE. 

Definition. — Frequency. — Predisposition  as  to  sex. — Clinical  history. — Stages  of  the 
affection. —  Symptoms. —  Pains. —  Distortion. — Curvature. — Torsion. — Varieties 
of  lateral  curvature. —  Etiology. —  Pathology. —  Diagnosis. —  Prognosis. —  Pre- 
ventive measures. — Treatment. 

By  this  term  is  understood  a  constant  deviation  of  the  spinal 
column,  or  a  portion  of  it,  to  either  side  of  the  median  line  of  the 
body,  with  a  resulting  distortion  of  the  trunk.  The  affection  has 
also  been  called  scoliosis,  and  rotary  lateral  curvature. 

In  French  it  is  known  as,  Scoliosc,  deviation  latci'ale  de  la  taille, 
and  in  German  it  is  called  SeitlicJie  Riickgratsverkri'nnnmng. 

Lateral  curvature  is  either  congenital  or  acquired.  The  former 
variety,  however,  is  exceedingly  rare ;  when  present,  it  is  either  a 
result  of  foetal  rickets  or  it  is  an  accompaniment  of  imperfect  de- 
velopment, and  inequality  in  the  formation  of  the  different  sides  of 
the  trunk  (Vogt,  "  Moderne  Orthopaedik,"  p.  75  ;  Schreiber,  "  Ortho- 
paedische  Chirurgie,"  p.  118). 

Ketch  (^New  York  Medical  Journal,  April  24th,  1886),  generalizing 
from  229  cases,  concluded  that  lateral  curvature  usually  begins 
from  the  8th  to  the  15th  year. 

In  52  per  cent  of  the  cases  the  distortion  began  between  the  1st 
and  1 2th  year. 

In  41  per  cent  from  the  12th  to  the  i8th,  and  3  to  4  per  cent 
from  the  i8th  year  upward. 

Eulenburg  in  1,000  cases,  noted: 

78  between  birth  and  the  6th  year. 
216         "         the     6th  and  7th  years. 
564         "  "       7th  and  loth  years. 

107         "  "     loth  and  14th  years. 

35   above  the  14th  year. 

Mr.  Willett  has  described  a  congenital  case  of  this  deformity  in  a 
specimen  examined  by  him.  The  dorsal  spine  was  altered  by  a 
slight  anterior  and  left  lateral  curve ;  four  and  a  half  of  the  dorsal 


I04  ORTHOPEDIC  SURGERY. 

vertebrae  were  missing,  five  ribs  on  the  right  side  and  four  on  the 
left  were  absent,  the  left  clavicle  was  out  of  shape,  and_the  scapula 
was  connected  by  a  bridge  of  bone  with  the  sixth  cervical  verte- 
bra. The  deformity  is,  in  his  opinion,  due  to  an  early  defect  in  the 
elements  forming  the  vetebral  and  lateral  plates  in  the  embryo. 

This  malformation  was  found  in  an  adult  woman  who  had  given 
birth  to  a  living  child,  and  who  died  of  pericardial  effusion  in  her 
thirty-first  year.  The  specimen  is  almost  unique  occurring  in  a 
person  oi  this  age,  a  list  of  specimens  in  the  English  museums 
giving  only  one  other  similar  case  in  an  adult,  sixty-four  years  old. 

Shakespeare,  often  accurate  in  medical  details,  was  probably  un- 
aware of  the  infrequency  of  congenital  scoliosis.  These  are  the 
words  of  Gloster  describing  his  distorted  back : 

"  I,  that  am  curtailed  of  this  fair  proportion, 
Cheated  of  feature  by  dissembling  nature, 
Deformed,  unfinished,  sent  before  my  time 
Into  this  breathing  world,  scarce  half  made  up." 

Frequency  of  the  Deformity. 

The  frequency  of  scoliosis  may  be  estimated  by  Drachmann's 
figures,  who  found  in  1884,  on  examining  28,125  school  children  in 
Denmark  (16,789  boys,  11,386  girls),  368  cases  of  scoliosis,  one  and 
one-third  per  cent. 

Fisher  states  that  of  3,000  cases  of  deformity  brought  to  the 
National  Orthopedic  Hospital  of  London,  937  were  affections  of 
the  spinal  column,  and  353  were  lateral  curvature. 

Berend  reports,  900  scoliotic  patients  in  3,000  patients ;  Lang- 
gaard,  700  in  1,000  cases;  Schilling,  600  in  1,000  (Schreiber). 

These  figures,  however,  taken  from  foreign  authorities,  do  not 
necessarily  represent  the  numbers  to  be  found  in  American  hospi- 
tals. 

The  writer  had  occasion  to  observe  the  great  number  of  adults 
with  distorted  spines  to  be  met  with  in  Dresden,  and  for  eleven 
successive  days  noted  the  number  of  these  deformities  among  the 
first  300  adult  persons  met.  Only  those  on  the  same  side  of  the 
street  who  were  passing  in  an  opposite  direction  were  counted. 
The  counts  were  made  during  walks  at  noon  in  the  crowded  part 
of  the  city  (Alt  Markt  and  Schloss  Strasse).  No  opportunity 
was  taken  to  examine  these  deformed  persons,  some  of  whom  were 
probably  cases  of  cured  Pott's  disease.  Cases  of  light  curvature 
and  those  not  easily  recognized  at  a  glance  were  not  noted.  The 
count,  which  consisted  only  of  the  severest  type  of  distortion,  re- 
sulted as  follows : 


LATERAL    CURVATURES   OE    THE  SPINE. 


lO: 


In  different  300  people  met  Aug.     1,  1872,  there  was  i  scoliotic. 


2                ' 

'           were  3 

3 
4 
5 
6 

"    4 

"  3 
"  2 
"     2 

7 
8 

'  was  I 
"     0 

9 
10 

"  0 
"     0 

II            ' 

'          were  2 

12            ' 

TO                                      ' 

'            was  I 

13 


were  3 


August  8,  six  cases  were  seen  on  the  other  side  of  the  street,  but 
not  noted. 

A  later  observation  for  two  successive  days  in  1883  gave  similar 
results. 

Similar  observations  in  other  localities  visited  have  indicated 
the  same  frequency  of  deformities. 

A  count  in  the  city  of  Boston  made  at  noon  on  a  pleasant  day  in 
summer,  at  a  part  of  the  city  filled  with  the  persons  visiting  the 
shops,  gave  as  a  result :  One  slight  case  of  scoliosis ;  one  dwarfed 
person  where  a  slight  curve  was  suspected.  No  cases  of  the  sever- 
est form  of  deformity  in  1,000  passers. 

Predisposition  as  to  Sex. — The  distortion  is  more  common  in  girls 
than  in  boys,  and  in  the  proportion  of  from  four  or  five  to  one. 

Ketch  found  189  females  and  40  males. 

Kolliker  found  577  females  and  144  males. 

But  of  the  most  severe  forms  of  the  disease  there  were  more 
males  than  females,  and  it  is  probable  that  if  parents  were  as  solic- 
itous as  to  slight  variations  in  the  figures  of  their  boys  as  of  their 
girls,  that  the  statistics  would  show  a  greater  proportion  among 
boys  than  has  been  reported ;  an  opinion  which  is  held  by  Vogt. 
In  the  lateral  curvatures  of  young  children  (under  five)  the  males 
are  said  to-  equal  or  to  outnumber  the  females. 

Bernard  Roth  found  in  200  cases,  183  girls;  Wildberger,  out  of 
120  cases,  loi  girls;  Berend  in  896  cases,  773  girls. 

Out  of  173  cases  collected  by  Adams,  151  were  females,  22  were 
males. 

Drachmann  found  the  proportion  of  girls  to  boys,  that  of  eight 
to  two. 

The  percentage  of  cases  which  are  girls  as  compared  to  boys,  has 
been  stated  by  Eulenburg  as  ten  to  one,  and  by  Kolliker  as  five 
to  one. 


Io6  ORTHOPEDIC  SURGERY. 


Clinical  History. 


It  should  be  distinctly  borne  in  mind  that  true  lateral  curvature 
is  not  a  disease  in  any  true  sense  of  the  word,  but  a  distortion  of 
growth. 

The  deformity  appears  and  is  developed  during  the  growing 
years ;  becoming  arrested,  as  a  rule,  at  the  end  of  the  period  of 
growth,  and  its  subsequent  changes  are  simply  those  which  occur 
elsewhere  in  the  osseous  system  as  a  result  of  the  wear  and  tear  of 
use. 

The  affection  may  be  divided  into  three  stages: 

1.  Initial  stage. 

2.  Stage  of  development. 

3.  Stage  of  arrest,  or  quiescence. 

Initial  Stage. — The  affection  is  ordinarily  discovered  by  the  pa- 
tient's mother  at  the  age  just  previous  to  puberty.  It  has,  how- 
ever, been  shown  that  it  has  developed  earlier  than  this  in  a  ma- 
jority of  cases,  but  is  not  recognized. 

Lateral  curvature  is  not  usually  seen  in  it  earliest  stage.  At  this 
period  of  it,  the  symptoms  are  so  slight  and  the  deformity  so  easily 
overlooked  that  the  surgeon  is  rarely  consulted.  The  patient  suf- 
fers no  inconvenience  at  this  period,  and  as  the  child  is  at  an  age 
(seven  to  ten)  when  the  figure  is  not  carefully  scrutinized,  little 
attention  is  paid  to  the  slight  elevation  of  the  shoulders  or  projec- 
tion of  the  hip.  Upon  examination,  but  little  else  is  to  be  seen,  and 
these  symptoms  disappear  on  recumbency  or  suspension.  Tests 
as  to  the  strength  of  the  muscles,  sometimes  show  a  comparative 
lack  of  muscular  force,  but  this  is  frequently  not  the  case.  A  care- 
ful examination  usually  discloses  a  peculiarity  in  standing  or  sit- 
ting. A  disposition  to  bear  weight  in  the  attitude  of  rest  on  one 
side  more  than  on  another  is  frequently  noticed,  and  also  an  inclin- 
ation of  the  trunk  to  one  side  of  the  vertebral  line. 

State  of  Development. — In  a  majority  of  cases  when  the  surgeon 
is  consulted,  well-marked  development  of  the  distortion  has  already 
taken  place.  The  curves  are  either  flexible  curves,  that  is,  nearly 
disappearing  on  recumbency  of  the  patient,  or  when  the  patient  is 
suspended;  or  dive  fixed,  when  little  change  of  the  curve  takes  place 
in  removing  the  weight  from  the  spinal  column.  Cases  vary  greatly 
in  the  rate  of  progress  made. 

The  muscular  system  may  or  may  not  be  well  developed ;  but  in 
a  majority  of  cases  the  muscles  are  not  large  or  strong. 

In  the  early  periods  of  the  development  of  the  affection,  there  is 
rarely  any  symptom  complained  of  except  the  annoyance  of  the 


LATERAL    CUK  VATUA'JlS   Ol'     7'/fK  SPINE.  107 

curvature,  due  to  a  distortion  of  the  fi^^ure.  In  a  few  instances  of 
growing  girls  with  marked  impairment  of  strength,  some  thoracic 
pain  maybe  felt,  and  fatigue  on  exertion  of  walking  or  standing. 
In  addition  to  this,  sensitiveness  and  burning  sensations  of  the 
back  maybe  found,  thougli  these  latter  are  more  pr^jperiy  attribut- 
able to  a  disordered  condition  of  the  nervous  system,  classed  as 
neurasthenia,  than  directly  to  the  lateral  curve. 

The  period  during  which  the  curvature  of  the  spine  may  develop 
is  indefinite,  as  well  as  is  the  rate  and  extent  of  the  development. 
It  is  impossible,  in  the  present  stage  of  our  knowledge,  to  predict 
the  amount  of  increase  or  the  permanency  of  arrest. 

The  liability  to  increase  is  greater  during  the  growing  years,  and 
there  is  some  ground  for  a  belief  that  the  chief  danger  of  increase 
is  during  this  period.  But  cases  of  severe  curvatures  will  be  seen 
where  development  has  slowly  continued  during  the  years  of  adult 
life. 

Stage  of  Convalescence,  Quiescence,  and  Arrest. — While  it  is  cer- 
tainly true  that  the  time  when  a  curve  may  be  regarded  as  arrested 
is  not  easily  recognized,  an  examination  of  a  large  number  of  un- 
treated cases  justifies  an  opinion  that  spontaneous  arrest  takes 
place  in  a  very  large  number  of  the  slighter  cases,  without  further 
development  of  the  deformity.  Even  in  many  of  the  severer  types 
of  the  deformity,  patients  will  be  observed  who  go  through  life 
without  any  increase  of,  or  inconvenience  from,  the  deformity. 

No  sharp  distinction  as  to  stages  of  development  and  arrest  can 
be  made,  but  the  classification  of  this  sort  has  its  value  in  consider- 
ing treatment. 

In  general,  it  may  be  said  that  the  initial  stage  corresponds  to 
childhood  and  the  approach  of  puberty;  the  stage  of  develop- 
ment extends  from  the  period  of  commencing  puberty  to  the  es- 
tablishment of  growth,  and  the  stage  of  arrest,  or  quiescence,  in- 
cludes a  period  after  completion  of  osseous  development. 

Symptoms. — Pain.  The  symptoms  depend,  in  general,  upon  the 
amount  of  distortion,  but  this  rule  is  not  an  absolute  one,  as  in  cer- 
tain individuals  slight  irritation  produces  a  greater  amount  of  pain 
than  in  others  less  deformed.  Symptoms  are  as  a  rule  not  com- 
mon in  the  affection. 

The  symptoms  of  pain  are  of  three  classes: 

1st.  Those  due  directly  to  the  altered  muscular  or  ligamentous 
strain. 

2d.  Those  due  to  the  abnormal  pressure  from  distorted  ribs  or 
vertebrae  upon  nerves,  or  to  alteration  of  the  size  and  shape  of  the 
thorax,  and  displacement  of  viscera. 

3d.  Neurasthenic  symptoms  from  a  lack  of  vitality,  superinduced 


I08  ORTHOPEDIC  SURGERY. 

by  the  limitations  as  to  exercise  and  activity,  consequent  on  the 
deformity. 

Cases  of  shght  curves  are  practically  free  from  symptoms  of  pain, 
and  in  the  milder  types  of  the  deformity,  at  the  stage  of  quiescence 
or  arrest,  no  symptoms  are  complained  of  if  the  patient  is  in  good 
health;  if,  hoAvever,  the  health  becomes  enfeebled,  slight  neuralgic 
pain  in  the  sides  of  the  thorax  is  occasionally  felt.  This  is,  usually, 
accompanied  by  paraesthesia,  or  hyperaesthesia  in  certain  parts  of 
the  back,  in  the  upper  dorsal  or  lumbar  region ;  but  in  the  severest 
types  of  the  deformity,  symptoms  directly  due  to  the  distortion  may 
be  observed,  viz.,  neuralgic  pains  from  abnormal  pressure  upon 
nerves  and  from  undue  strain  upon  ligaments  and  fasciae,  occa- 
sioned by  distorted  attitudes. 

The  pain,  which  is  usually  located  in  the  lumbar  region  and  down 
the  thighs,  is  worse  after  fatigue,  and  is  relieved  in  a  measure  by 
removing  the  superincumbent  weight,  but  it  is  often  impossible  to 
determine  whether  these  symptoms  are  due  directly  to  the  curva- 
tures or  to  a  concomitant  neurasthenia. 

Tenderness  on  pressure  is  never  present  in  pure  lateral  curvature, 
and  when  found  it  is  an  evidence  of  nervous  depression. 

General  Symptoms. — Interruption  in  the  functions  of  the  liver, 
stomach,  and  intestines,  is  mentioned  by  Adams,  as  occasionally 
seen  in  severe  cases.  Shortness  of  breath  also  occurs  as  well  as 
pain  in  the  stomach,  loss  of  appetite,  and  indigestion. 

In  the  severest  cases  a  lack  of  deposit  of  fat  in  the  subcutaneous 
tissue  will  be  noticed  and  the  patients  are  thin,  even  though  they 
may  be  in  relatively  good  health. 

The  neurasthenic  symptoms  are  chiefly  manifested  by  indisposi- 
tion to  exertion,  vague  complaints  of  pain  and  discomfort,  and  ten- 
derness in  the  back.  These  symptoms  are  rarely  as  marked  in 
lateral  curvature  as  in  the  pure  forms  of  spinal  irritation,  but  they 
may  be  added  to  the  symptoms  directly  due  to  the  distortion. 

In  many  of  the  severest  forms,  the  patients'  lives  are  made  mis- 
erable by  a  variety  of  symptoms  probably  referable  to  impaired 
circulation,  feeble  digestion,  lack  of  energy,  and  limited  powers  of 
respiration.  The  symptoms  are,  in  part,  due  to  the  mechanical 
compression  of  the  deformed  thorax;  and  in  part,  to  a  lowered  con- 
dition of  the  nervous  system,  as  is  seen  in  ordinary  cases  of  neuras- 
thenia from  mental  anxiety  and  the  limitations  of  the  surroundings. 

Distortion. — The  chief  symptom  of  lateral  curvature  is  necessa- 
rily the  distortion,  which,  even  when  not  severe  enough  to  occasion 
discomfort,  is  aways  a  source  of  mortification  and  annoyance  to 
the  patient. 

The  distortion  is  not  limited  to  a  simple  curvature  of  the  spine„ 


LATERAL   CURVATURJCS   OF    THE  S/'/NE. 


109 


but,  as  will  be  described  later,  to  this  is  added  a  twistiii^  of  the 
whole  trunk;  or,  In  other  words,  there  is  both  a  curvature  and  a 
torsion  on  a  vertical  axis. 

Curvature. — The,  curvature  of  the  spinal  column  varies  in  degree, 
situation,  and  extent. 

The  variations  are  so  great  that  no  two  curvatures  are  precisely 
alike,   as  is  evident  from  the  accompanying  illustrations.     There 


Fig.  114. — Projection  of  Shoulder  in  Right  Convex  Dorsal  Curvature.     Fig.  115. — Upper  Dorsal  Curvature. 

are,  however,  common  types,  which  it  is  convenient  to  bear  in 
mind  in  considering  the  subject  of  treatment. 

If  one  lateral  cuvre  occurs  in  the  middle  region  of  the  spinal 
column,  it  necessitates  two  other  compensating  curves  in  opposite 
directions,  one  above  and  one  below  the  deformity,  in  order  to  keep 
the  head  erect  and  in  the  median  line.  These  compensating  curves 
may  or  may  not  be  of  pathological  significance. 

If  not,  the  lateral  curvature  consists  of  a  single  curve,  which  may 
be  situated  in  different  parts  of  the  column.  In  some  instances 
one  of  the  compensating  curves  is  of  an  equal  prominence  with  the 


no 


ORTHOPEDIC  SURGERY. 


so-called  primary  curve;  in  which  case  the  spinal  column  will  pre- 
sent the  S-shaped  curve  which  is  characteristic  and  which  is  illus- 
trated in  the  accompanying  pictures.  In  other  cases,  what  is 
termed  the  compensating  curve  may  become  more  marked. 

The  curves  are  often  termed  either  dorsal  or  lumbar,  but  they 
are  rarely  limited  exactly  to  these  portions  of  the  spinal  column ; 
in  most  instances,  also,  the  curves  are  not  typical ;  the  upper  curve 
may  be  so  long  as  to  include  all  of  the  dorsal  and  upper  lumbar 
vertebrae,  so  that  the  prominent  hip,  due  to  the  sinking  away  and 
rotation  forward  of  the  lower  ribs  on  the  side  of  the  concavity, 
may  not  be  the  right,  but  the  left  hip;  although  the  right  shoulder 
is  raised.     Again,  the  lower  curve  may  be  so  long  as  to  invade 


Fig.  ii6. — Curvature  in  the  Cervical  Region. 


Fig.  117. — Dorsal  Curvature. 


nearly  the  whole  of  the  dorsal  region,  the  compensation  taking  place 
in  the  upper  part  of  the  cervical  region. 

In  both  these  varieties  of  curves,  compensating  curves,  so-called, 
are  necessarily  present.  They  may  be  so  slight  as  not  to  attract 
attention,  or  they  may  constitute  a  curve  of  equal  severity  with 
the  upper  or  lower  curves,  forming  a  double  curve. 

Furthermore,  when  the  curves  are  in  the  flexible  stage  it  is  diffi- 
cult to  determine  which  is  the  more  important  one;  but  after  osse- 
ous changes  have  taken  place,  the  most  important  curves  become 
fixed,  and  these  are  the  curves  which  demand  most  attention. 
This  is  partly  due  to  the  attitude  in  which  the  column  is  placed, 
and  partly,  probably,  to  a  lack  of  resistance  of  certain  parts  of  the 
spinal  column. 


LATERAL    CURVATURES   OF    77/ A'  SI'/NE. 


I  I  I 


Cervical  CiirvaULrc. — The  cervical  or  \\\^'\  dorsal  curves  arc  the 
least  common  forms  of  lateral  curvature,  except  when  associated 
with  torticollis. 

This  curvature  may,  however,  occur  primarily  ;  when  it  does,  it  is 
more  commonly  accompanied  by  a  long  compensatory  lower  curve, 
as  in  the  accompanying  picture.     There  is  invariably  elevation  of 


Fig.  ii8. — Projection  of  Hip  in 
Lumbar  Curvature. 


Fig.  iig.  —  Front  View  of  Lateral  Curvature,  showing  Promi- 
nence of  Left  Mamma  in  Right  Dorsal  Convex  Curvature. 


one  shoulder  and  an  inclination  of  the  axis  of  the  head  to  the  side 
of  the  concavity  of  the  cervical  curve. 

Dorsal  Curvature. — The  most  common  dorsal  curve  is  with  the 
convexity  to  the  right.  In  these  cases  the  right  shoulder  will  be 
raised,  the  right  shoulder-blade  will  project  backward  more  promi- 
nently than  the  left,  and  Avill  be  at  a  higher  horizontal  level  and 
farther  from  the  median  line  of  the  trunk.  The  back,  just  below 
the  scapula,  will  be  more  rounded  backward  on  the  right  side,  and 
more  flattened  on  the  left,  and  the  left  shoulder  will  be  held  down. 


112 


ORTHOPEDIC  SURGERY. 


In  front,  in  well-marked  cases,  the  breast  may  be  more  prominent 
on  the  left  than  on  the  right  side. 

In  addition  to  the  curve  there  may  be  a  tendency  to  incline  the 


Fig.  I20. — Antero-postenor  Curvature 
in  Lateral  Curve. 


Fig.  121. — Dorsal  Curvature. 


Fig.  122. — Low  Dorsal  Curve. 


Fig.  123. — Low  Dorsal  Curve. 


LATERAL    CURVATURES   ()/'     TJ/E  S/'JNI-: 


"3 


whole  trunk  to  tlic  rit^lit  side.  VVIicrc  tliis  is  tlic  case,  the  ri^ht 
arm  when  hanging,  will  be  free  from  the  side,  while  the  left  arm, 
when  hanging  down,  necessarily  strik'es  the  hip. 

There  is  also,  unavoidably,  a  change  in  the  outline  of  the  sides 
of  the  back.  The  sides,  instead  of  being  symmetrical,  as  seen  from 
the  back,  will  be  different,  the  left  side  of  the  outline  will  be  un- 
naturally straight,  and  on  the  other  more  than  normally  hollowed. 


Fig.  124. — Lateral  Curvature — Long  Right  Convex  Dorsal 
Curve. 


Fig.  125. — Double  Lateral  Curvature. 


Lumbar  Curvatitre. — The  lower  dorsal  or  lumbar  curvature  mani- 
fests itself  by  a  prominence  of  one  of  the  hips ;  most  frequently  the 
right,  sometimes  the  left.  In  well-marked  cases  there  is  also  a  ful- 
ness in  the  back  on  the  left  side",  above  the  crest  of  the  ilium ;  and 
a  corresponding  flattening  on  the  left  side.  In  front  the  umbilicus 
is  at  the  side  of  the  median  line.  The  most  common  lumbar  curve 
is  with  the  convexity  to  the  left. 

A  difference  in  the  outlines  of  the  two  sides  of  the  back,  already 
mentioned,  is  also  seen  in  this  form  of  curvature. 
8 


114 


OR  THOPEDIC  S  URGER  V. 


A  sharp  clinical   distinction   between   lumbar   and   lower   dorsal 
curves  is  not  practicable,  as  they  resemble  each  other  in  regard  to 


Fig.  126.— Slight  Double  Lateral        Fig.  127.— Double  Curvature. 
Curvature. 


Fig.  128. — Double  Curvature. 


Fig.  129. — Lower  Dorsal  and  Lumbar  Curvature. 


Fig.  130. — Double  Curve. 


the    resulting   distortion.      A  combination   of  lumbar    and  dorsal 
curves  will  of  course  present  the  features  of  both  varieties,  but  the 


LATERAL    CURVATURES   OE    THE  SJLNE. 


115 


distortion  of  the  most  pronounced  curve  predominates.  If  the 
curves  are  equal,  a  double  curvature  is  said  to  exist,  in  which  case  the 
leaning  to  one  side  is  not  as  marked  as  in  long,  single,  dorsal  curves. 

The  curves  maybe  reversed;  but  the  more  common  ones  are 
those  indicated  with  the  upper  convexity  to  the  right  and  the  lower 
convexity  to  the  left.  When  this  is  the 
case,  the  distortion  will  be  correspondingly 
altered. 

Localization. — Some  writers  regard  the 
lumbar  scoliosis  as  the  chief  curve,  and  as 
most  common. 

The  question   may  be   regarded  as  not 


Fig.  131. — Left  Convex  Dorsal  Curvature. 


Fig.  132. — Sharp  Left  Convex  Dorsal  Cur\-e. 


settled,  though  for  clinical  purposes  it  may  be  accepted  as  a  fact 
that  the  dorsal  curve  is  the  one  most  frequently  requiring  treatment. 

Limping. — In  certain  very  severe  cases  the  distortion  of  the  ver- 
tebral column  is  so  great  that  the  pelvis  is  secondarily  tilted,  and 
by  this  one  leg  is  rendered  shorter  than  the  other  for  practical 
purposes  and  a  more  or  less  marked  limp  may  be  caused. 

In  721  cases,  Kolliker  found  one  prominent  lateral  curve  in  466 
cases.' 


'Centralbl.  f.  Chir.,  No.  21,  1SS6. 


Il6  ORTHOPEDIC  SURGERY. 

In  the  number  examined,  391  were  in  the  dorsal  region;  208  of 
these  were  with  the  convexity  to  the  right  and  183  with  the  con- 
vexity to  the  left. 

222  cases  showed  double  prominent  curves,  and  of  these  172 
were  with  the  upper  curve  a  convexity  to  the  right  and  the  lower 
curve  convex  to  the  left. 

42^  per  cent  of  the  number  examined  by  Drachmann;  92 
per  cent  of  those  reported  by  Eulenburg;  84  per  cent  accord- 
ing to  Adams,  and  81  per  cent  according  to  Heiner,  presented 
curves  in  the  upper  dorsal  region  with  the  convexity  toward  the 
right.  Lorenz  and  Drachmann  think  that  the  lumbar  lateral  curv- 
ature with  the  convexity  toward  the  left  is  more  frequent  than  has 
been  thought.  Lorenz  found  in  163  cases,  62  lumbar  curves  and 
64  dorsal;  and  Klopsch  found  71  lumbar  curves  in  121  cases.  Lat- 
eral curvature  with  the  convexity  toward  the  left  is  more  com- 
mon in  young  children. 

Out  of  569  cases  in  the  Royal  Orthopedic  Hospital  of  lateral 
curvature,  470  cases  presented  curvature  with  convexity  toward 
the  right  side,  99  to  the  left  side. 

Of  Adams's  and  Lonsdale's  173  cases,  in  149  the  convexity  was  to 
the  right  side,  and  in  24  the  convexity  was  to  the  left  side.  Some 
discussion  has  taken  place  as  to  which  is  to  be  regarded  as  the 
primary  and  which  the  secondary  curve  in  cases  of  double  scoliosis. 

Bouvier,  Malgaigne,  and  most  French  writers  claim  that  the  dor- 
sal curvature  toward  the  left  is  the  one  which  is  first  formed  and 
that  the  lumbar  curve  is  generally  much  smaller,  with  the  concav- 
ity to  the  right  and  secondary  (see  Malgaigne);  this  is  denied, 
however,  by  many  surgeons,  notably  Alexander  Shaw,  who  consid- 
ers that  the  lumbar  curve  is  the  primary  one  and  that  the  dorsal 
curve  is  secondary. 

According  to  Shenk,  the  lumbar  curve  is  the  most  common 
primarily,  but  the  dorsal  curve  is  most  commonly  brought  to  the 
attention  of  physicians  on  account  of  the  greater  deformity  due  to 
a  torsion  of  the  ribs. 

Torsion. — As  is  explained  under  the  head  of  pathology,  it  is  im- 
possible for  any  curvature  to  take  place  in  the  spinal  column  with- 
out being  accompanied  by  torsion  of  the  vertebrae,  or  rotation,  as 
it  is  frequently  termed. 

The  prominence  of  torsion  in  lateral  curvature  is  a  measure  of 
the  severity  of  the  case.  It  is  to  this  torsion  of  the  vertebra  that 
is  due  the  necessary  alteration  of  the  position  of  the  ribs,  the 
■prominence  of  the  shoulder  blade  as  well  as  the  flattening  of  the 
chest  on  one  side,  the  difference  in  prominence  of  the  breasts,  and 
of  the  hips,  and  also  the  lumbar  fulness. 


LATERAL    CURVATIIKKS    OF    77 /K  S7'7N7':. 


117 


These  symptoms  of  torsion  may  be  present  before  any  curvature 
can  be  determined  in  the  line  of  the  spinous  processes,  the  projec- 
tion of  the  shoulders,  or  of  the  hip,  constituting  the  first  evidence 
of  lateral  curvature. 

Torsion  presents  the  most  characteristic  and  distressing  symp- 
tom of  lateral  curvature,  for  it  not  only  causes  the  projection  of  the 


/^      %^ 


Fig  133. — Left  Convex  Dorsal  Curve. 


Fi(,   ij4 — I    u<.r  J  )ii-.al  Lur\ature. 


shoulder  and  the  hip — the  most  disfiguring  part  of  the  deformity — 
but  it  is  from  torsion  and  its  consequences  that  the  greatest  con- 
traction of  the  chest  and  resulting  disturbances  are  due. 

The  amount  of  torsion  may  be  much  greater  than  would  be  ex- 
pected by  a  slight  amount  of  apparent  lateral  deviation  of  the 
spinous  processes,  as  if  the  vertebrae  yielded  more  by  twisting 
under  superincumbent  weight  than  in  a  sideway  curve. 

Varieties  of  Lateral  Curvature. 

The  varieties  of  lateral  curvature  are  in  all  probability  not  as 
numerous  as  some  Avriters  would  lead  us  to  suppose,  but  as  there 
are  many  different  causes  which  may  produce  the  distortion,  a 
number  of  varieties  may  be  readily  classified. 

A  lateral  deviation  is  sometimes  seen  in  an  early  stage  of  caries 
of  the  spine,  and  at  the  later  stages  in  untreated  or  neglected  cases 
when  the  consolidation  of  the  carious  bone  has  taken  place  irregu- 
larly. 


ii8 


OR  TH  OP  ED  It    S  UR  GER  V. 


This  distortion  may,  naturally,  follow  fracture  or  dislocation, 
and  is  occasionally  seen  in  the  rare  affection,  spondylolisthesis,  de- 
scribed in  another  chapter. 

In  sacro-iliac  disease  a  curvature  of  the  spine  due  to  the  pecu- 


FiG.  135. — Low  Dorsal  Curve. 


Fig.  13?.  Fig.  137. 

Fig.  136  and  137. — Rhachitic  Lateral  Curves.' 


liarity  of  the  attitude  is  quite  constant,  and  in  torticollis  scoliosis 
necessarily  follows. 

RliacJiitic  Lateral  Ctirvatiire. — This  form  occurs  in  rhachitic  chil- 
dren ;  but  it  is  not  so  common  a  curve  as  the 
antero-posterior  curve  which  appears  as  a  back- 
ward prominence  in  the  lumbar  region  in  so 
many  cases  of  rickets. 

The  pure  rhachitic  lateral  curvature  has,  ac- 
cording to  Lorenz,  its  greatest  curve  in  the  mid- 
dle of  the  spinal  column,  and  is  more  likely  to 
be  characterized  by  convexity  to  the  left. 

Guerin  claims  that  rhachitic  children  show  a 
lateral  curvature  in  9.7^  of  cases.  Eulenburg 
found  that  in  rhachitic  scoliosis,  the  period  of 
development  of  the  curve  was  in  the  first  six 
months  in  54^  of  the  cases,  and  that  the  per- 
centage diminished  to  nothing  at  the  seventh 
year.  The  affection  is  as  common  in  boys  as  in 
girls.  The  distortion  may  or  may  not  be  ac- 
companied by  other  evidences  of  rickets,  but 
in  most  cases  the  other  signs  of  the  disease  are 
marked. 

In  some  varieties  of  lateral  curvature  there  may  also  be  an  exag- 
gerated antero-posterior  curve  due  to  yielding  of  the  bones  under 
the  unsual  distribution  of  superincumbent  weight. 


Fig.  138. — Lateral  Curvature 
in  Sacro-lliac  Disease. 


LATERAL    CURVATURKS   01'     Till':  Sl'fNE. 


IKj 


Static  Lateral  Curvature.  -T\\\'~>  term  is  ai)[jHc(l  to  that  form  due 
to  inequality  of  the  Icn^4h  of  the  le^s. 

A  slight  difference  in  the  length  of  the  lower  limbs  is  the  rule,  as 
will  be  shown  under  another  heading.  But  development  of  lateral 
curvature  directly  from  this  cause  is  exceptional,  as  is  evident  from 
the  fact  that  in  a  comparatively  small  number  of  cases  of  scoliosis, 

a  noticeable  difference  is  detected  in 
the  length  of  the  lower  limbs. 
i^^miwrnf/  Sklifosowsky  found  in   21    cases  of 

lateral    curvature,    inequality    in    the 
length  of  the  limbs  in  17  {Ccntralblatt 


Fig.  139. — Slight  Lumbar  Curve  Accompanying  Knock 
Knee  and  Resulting  Shortening  of  One  Limb. 


Fig.  140.— Lateral  Cur\'ature  Following  Marked 
Inequality  m  Length  of  Legs. 


/.  Chir.,  1884,  p.  43).  Staffel  found  in  230  cases  of  scoliosis  the 
left  leg  shorter  in  62  cases.  H.  L.  Taylor  found  28  cases  of 
shortening  of  the  left  leg  in  32  cases  of  scoliosis. 

Furthermore,  from  only  a  comparatively  small  number  of  cases 
of  clearly  defined  shortened  limbs  from  infantile  paralysis,  hip  dis- 
ease, etc.,  does  true  scoliosis  result.  In  a  certain  number  of  cases, 
however,  of  shortened  limbs  from  these  affections,  a  marked  lateral 
curvature  is  found  in  some  cases  characterized  by  rotation  of  the 
ribs. 


120  ORTHOPEDIC  SURGERY. 

That  curvature  should  develop  in  some  instances  and  not  in 
others,  is  probably  due  to  the  fact  of  the  existence  in  certain  of 
these  cases  of  less  resistance  of  the  spinal  column  to  unfavorable 
conditions. 

Paralytic  Lateral  Ciirvatiirc. — In  a  certain  number  of  cases  of 
paralysis  of  the  muscles  of  the  back,  lateral  curvature  of  the  spine 
is  found. 

When  the  muscles  of  the  back  are  weak,  the  patient  instinctively 
assumes  an  attitude  in  which  the  spine  is  balanced  with  the  least 
action  on  the  part  of  the  weakened  muscles.  The  bones  of  the 
spine  may  be  affected  (if  lackirig  in  a  power  of  resistance)  by  a 
constant  vicious  attitude,  and  a  fixed  lateral  curvature  result. 

This  form  of  lateral  curvature  is  most  commonly  developed  after 
infantile  paralysis,  as  this  is  the  most  common  form  of  paralysis 
occurring  in  the  growing  years;  but  the  effect  of  other  palsies,  if 
influential  in  weakening  certain  muscles  of  the  back,  would  be  the 
same,  and  the  distortion  may  be  seen  after  spastic  paralysis,  pro- 
gressive muscular  hypertrophy,  and  other  affections  weakening  the 
muscles  of  the  spinal  column. 

Lateral  curvature  may  follow  empyema  and  some  deviation  of 
the  spinal  column  almost  necessarily  follows  severe  forms  of  em- 
pyema. In  the  purest  forms  of  this  type  there  is  no  true  scoliosis,  the 
spine  not  being  twisted  to  a  noticeable  extent,  but  simply  pulled 
to  one  side,  the  ribs  being  flattened,  i.e.,  fixed  obliquely  at  a  lower 
angle  than  normal,  from  the  cicatricial  contraction  of  the  lung 
which  prevents  expansion  of  the  lung  on  that  side  and  leads  to  an 
increased  expansion  on  the  other. 

In  certain  cases,  however,  the  altered  position  so  induced  has 
its  effect  upon  the  growth  of  the  spine,  and  a  true  lateral  curvature 
with  torsion  takes  place. 

It  has  been  said  that  a  curvature  followed  in  some  instances 
pneumonia  and  phthisis,  but  this  is  not,  according  to  Mr.  Adams, 
commonly  the  case. 

Lateral  curvature  in  a  case  of  sarcoma  of  the  ribs  and  lung  has 
been  reported  by  Shattuck  {^Boston  Med.  and  Surgical  Jojtrnal,  Jan. 
loth,  1889). 

Lateral  Curvature  from  Occupation. — Lateral  curvatures  of  severe 
type  due  to  occupation,  are  not,  as  a  rule,  so  common  as  other 
forms,  for  the  reason  that  laborious  occupations  are  not,  in  general, 
entered  upon  until  an  age  when  the  spinal  column  has  a  sufificient 
amount  of  resistance  to  withstand  the  superimposed  weight. 

Slight  lateral  curves  may  be  seen,  similar  to  the  kyphosis  of 
those  employed  in  occupations  requiring  stooping.  Scoliosis  in 
school   children  is,  in  fact,  a  curvature  from   occupation  in  a  true 


LATERAL    CURVATUKI'lS   ()/'    '/'J/IC  S/'/NJC. 


121 


sense,  though  the  tenn  as  (jrcliiiarily  used  is  not  so  aijplierl.  in 
clerks  one  shoulder  is  often  higher  than  tlie  other  from  the  at- 
titude of  writing,  and  it  is  said  to  be  true  also  in  blacksmiths. 
Severe  forms  of  this  class  are  sometimes  seen  in  adolescents 
whose  occupation  habitually  twists  the  spine,  as  in  carrying  bas- 
kets or  trays.  Mr.  Arbuthnot  Lane  has  called  special  attention  to 
this  fact,  and  has  also  observed  that  the  shape  of  the  lateral  curve 
varied  in  a  measure  with  the  occupation. 


Fig.  141.  Fig.  142. 

Figs.  141  and  142. — Lateral  Curvature  Following  an  Attack  of  Infantile  Paralysis. 

In  short,  occupations  which  require  constant  one-sided  attitudes, 
as  in  the  clerk,  artist,  blacksmith,  etc.,  may,  in  certain  individuals, 
develop  a  lateral  deviation  of  the  spinal  column  as  the  natural 
result  of  this  constant  position. 

Scoliosis  in  nursing  women,  from  carrying  infants  too  frequently 
upon  one  side,  is  also  recorded,  and  the  same  attitude  in  one-armed 
persons.  Lateral  curvature  from  a  peculiar  position  in  sitting  has 
also  been  noted  due  to  inequality  of  eyesight. 


122 


ORTHOPEDIC  SURGERY. 


A  twist  in  the  lower  part  of  the  spinal  column  is  seen  in  some 
forms  of  sciatica.' 

Physiological  Cu7've. — What  has  been  termed  a  physiological  curv- 
ature has  been  described  by  Bouvier.  Such  a  curve  is  usually 
found  with  the  convexity  to  the  right  in  the  dorsal  region ;  it  is 
sometimes  seen  at  autopsy,  but  not  in  young  children.  It  is  sup- 
posed to  be  due  to  the  Aveight  of  the  heart,  or  to  the  greater  use 
of  the  right  arm  or  right  side  of  the  body.     The  importance  of 


Fig.  143. — Lateral  Curvature  Following 
Empyema. 


f  IG.  144.— Slight  Flexible  Upper  Dorsal  Right 
Convex  Lateral  Curvature. 


this  curve  is  not  as  great  as  is  supposed  by  some  writers.  In  fact 
the  existence  of  this  curve  as  a  physiological  curve  has  been  denied 
by  many  authorities. 

Flexible,  Fixed,  and  StriicUiral  Curves. — Varieties  have  been  made 
by  some  writers  who  wish  to  classify  lateral  curvatures  as  flexible 
or  fixed  according  to  their  disappearances  or  persistence  on  a 
change  of  attitude. 

Structural  curves  are  described  as  those  where  a  change  in  the 
structure  and  shape  of  the  bones  has  taken  place. 


'  Ischias  Scoliotica,  Langenbeck,  Archiv,  i^ 


LATERAL    CUA'VATUAL-'.S   ()/'     77//':  S/'/N/i. 


123 


These  terms  are  convenient  in  describinj^  a  condition  of  tli<; 
spinal  column  according  to  the  stage  of  progress  of  the  affection 
and  the  amount  of  ligamentous  or  osseous  change  that  has  taken 
place,  but  they  should  be  used  in  no  wider  sense. 

Etiology. 

A  great  deal  has  been  written  on  the  subject  of  the  causation  of 
lateral  curvature,  and  the  question  is  still  a  vexed  one,  although 
at  present  the  weight  of  authority  favors  the  opinion  that  the  de- 
formity is  chiefly  brought  about  by  mechanical  influences. 

The  theories  advanced  to  explain  the  phenomena  of  lateral  curv- 
ature are  the  following: 

I.  That  the  distortion  is  due  to  unequal  muscular  action,  as  is 
true  in  torticollis.  2.  That  the  cause  is  to  be  found  in  an  inequal- 
ity of  growth  of  different  portions  of  the  vertebrae,  as  if  the  affec- 
tion were  to  be  classed  as  a  localized  unilateral  hypertrophy.  3. 
That  the  distortion  is  the  result  of  superincumbent  weight  acting 
upon  a  faulty  condition  of  the  spinal  column. 

One  of  the  most  notable  causes  alleged  for  those  cases  in  the 
first  group  is  that  of  active  muscular  contraction,  which  was  advo- 
cated by  Jules  Guerin,  who  believed  that  lateral  curvature  was 
caused  by  the  spasmodic  contraction  of  certain  muscles,  in  the 
same  way  that  the  head  is  twisted  in  torticollis.  As  a  result  of  this 
belief,  myotomy  of  muscles  on  the  concave  side  of  the  curve  Avas 
recommended  by  Guerin,  and  in  one  case  he  performed  thirty  or 
forty  muscular  divisions.  Both  this  method  and  theory  have  fallen 
into  discredit  at  present. 

The.  facts,  as  seen  clinically,  do  not  substantiate  such  a  theory. 
In  the  cases  of  true  lateral  curvature  at  an  early  stage,  not  only  is 
there  no  spasm  but  no  contraction  even  of  the  muscles  on  the  con- 
cave side  of  the  curve ;  and  the  contraction  seen  in  the  later  stages 
of  pronounced  curves  can  be  explained  by  the  supposition  of  the 
adaptive  shortening  of  the  muscles. 

It  may  be  assumed,  that  although  in  exceptional  cases  there  may 
exist  an  active  contraction  of  certain  muscles,  as  a  cause  for  lateral 
curvature  (as  is  the  case  in  torticollis  and  in  some  instances  of 
caries  of  the  ilium  or  lumbar  vertebrse),  yet  these  cases  are  so  ex- 
ceptional as  to  be  insufficient  to  establish  a  rule  for  the  treatment 
of  scoliosis.  Stromeyer  and  Barvvell  have  spoken  of  the  contrac- 
tion of  the  serratus  muscle  as  a  cause  of  this  deformity.  This, 
however,  has  not  found  general  acceptance. 

A  much  more  probable  presentation  of  the  muscular  theorv  is 
that  which  has  received  the  able  advocacy  of  Eulenburg  and  which 


124 


'ORTHOPEDIC  SURGERY. 


has  met  with  acceptance  from  many  authorities  and  been  the 
foundation  of  a  system  of  treatment. 

The  theory  may  be  stated  as  follows:  Continuous  muscular 
action  is  necessary  for  holding  the  trunk  erect.  If  all  the  muscles 
are  not  in  continuous  action  they  must  be  constantly  on  guard  to 
prevent  any  deviation  from  the  normal  position.  If  any  of  the 
muscles  are  weakened  the  spinal  column  will  tend  to  bend,  the 
deviation  falling  with  the  convexity  on  the  side  of  the  weakened 
muscles;  the  side  of  the  concavity  being  that  of  the  normal  mus- 
cles. In  weak  individuals,  habits  of  attitude,  continued  for  a  long 
time,  will  weaken  certain  muscles,  by  over-stretching  them,  and  will 
cause  distortion  to  ensue. 

The  objection  to  this  theory  is  that  it  cannot  satisfactorily  ex- 
plain all  the  facts.  No  diminution  in  the  strength  of  the  muscles 
has  in  the  early  cases  been  demonstrated,  and  such  as  has  been 
found  is  in  the  severe  cases  and  is  only  such  as  would  result  from 
the  long-continued  disuse  of  the  muscles.  Furthermore,  lateral 
.curvature  is  often  developed  in  individuals  of  apparently  strong 
muscles.  There  is,  moreover,  also  no  proof  that  muscles  are  weak- 
ened by  the  slight  over-stretching  which  follows  the  habits  of 
standing  or  sitting  seen  in  children.  As  Lorenz  has  justly  observed, 
the  habits  of  sitting  or  standing  on  one  leg  should,  if  Eulenburg's 
theory  is  correct,  develop  an  abnormal  attitude  of  the  hip,  knee, 
or  elbow,  from  muscular  action.  Of  this  there  is  no  proof;  and, 
moreover,  in  lighter  cases  of  scoliosis,  no  diminution  in  the  muscu- 
lar power  of  the  different  sides  can  be  demonstrated. 

Eulenburg's  theory  can,  however,  not  be  readily  dismissed. 
Even  if  the  purely  mechanical  theory  of  lateral  curvature  due  to 
static  influences  be  accepted,  it  is  presumable  that  the  faulty  atti- 
tudes frequently  assumed  by  children  in  sitting  and  standing,  may 
be  due  to  a  lack  of  strength  of  certain  groups  of  muscles,  either 
inherited  or  acquired  by  accident;  although  it  is  not  possible  to 
demonstrate  such  impaired  muscular  strength  of  these  muscles.  In 
other  words  muscular  weakness  may  be  regarded  as  a  predisposing 
influence,  if  not  an  actual  cause  of  the  deformity. 

With  this  in  view  it  is  alleged  that  the  distortion  is  probably  due 
to  disturbed  muscular  conditions  involving  impaired  muscular 
power  on  one  side.  The  muscles  primarily  affected  are  probably 
not  the  external  muscles  moving  the  spinal  column,  but  the  inter- 
nal group  which  pass  from  vertebra  to  vertebra,  and  act  on  the 
column  in  segments. 

The  second  theory,  that  of  abnormal  growth,  is  advocated  by 
Hueter  and   Engell,  who  believe  that  in   some   cases   there   is   an 


LATERAL    CURVATURES   OE    Tllk  SJLN/C.  125 

abnormal  growth  of  one  side  of  the  thorax,  including  the  ribs  and 
the  vertebrae,  similar  to  the  unilateral  atrophy  or  hypertrophy  seen 
elsewhere;  and  that  there  is  an  abnormal  ossification  at  the  ends 
of  the  ribs  in  early  childhood  from  which  cause  the  thorax  is 
twisted  and  developed  asymmetrically. 

Delpech  and  Bouvier  think  that  faulty  attitudes,  instead  of  being 
the  cause,  are  the  result  of  lateral  deviation,  which  are  themselves 
due  to  asymmetrical  development  of  the  bodies  of  the  vertebra;. 

The  position  of  the  heart  on  the  left  side  of  the  body  has  been 
explained  to  be  an  exciting  cause  for  lateral  curvature  with  the 
convexity  toward  the  right.  This,  however,  cannot  be  construed 
as  true,  as  in  the  case  of  Beclard,  where  there  was  transposition  of 
the  viscera  on  the  right  side  and  still  a  lateral  curvature  to  the  left 
side  existed.  And  in  left-handed  persons  the  left  shoulder  is  fre- 
quently found  higher  than  the  right. 

Many  objections  can  be  urged  against  this  theory;  but  the  most 
important  is,  that  it  does  not  correspond  with  clinical  facts. 

If  a  series  of  cases  be  collected  and  arranged  according  to  their 
severity,  it  will  be  found  that  in  the  lighter  cases  (differing  appar- 
ently only  in  degree  from  the  severer  ones),  no  abnormality  of 
growth  in  the  spinal  column  is  present.  No  evidence  has  been  ad- 
vanced to  support  the  theory  of  a  freak  of  growth  in  the  ordinary 
cases  of  lateral  curvature  ;  the  exception  to  this  statement  being 
only  the  rare  instances  of  congenital  imperfection  which  develop 
a  distortion  at  first  somewhat  resembling  lateral  curvature.  Fur- 
thermore, against  this  theory  it  may  also  be  urged  that  in  the  early 
stages  of  the  affection  these  curves  disappear  in  recumbency  and 
that  they  only  become  permanent  after  a  long  tim.e.  Lorinser  has 
advanced  a  theory  of  subacute  inflammatory  changes  in  the  structure 
of  the  bone,  but  there  is  little  to  be  said  in  support  of  such  a  view. 
Lesser  urged  the  view  that  the  unequal  action  of  the  different 
halves  of  the  diaphragm  through  unilateral  paralysis  of  the  phrenic 
nerves  gave  rise  to  the  deformity. 

The  doctrine  of  faulty  innervation  as  a  cause  of  scoliosis  has 
been  advanced,  but  it  has  not  yet  received  any  acceptance. 

The  third  theory  is  that  of  superincumbent  weight.  The  ma- 
jority of  authorities  favor  this  theory,  which  is  urged  by  Roser 
and  Volkmann,  who  consider  the  deformity  as  the  result  of  the 
gradual  mechanical  force  of  the  superincumbent  weight  falling 
upon  the  spinal  column  which  is  not  held  erect,  and  which  is  in- 
capable of  resisting  the  pressure  which  falls  upon  it. 

The  clinical  facts  conected  with  lateral  curvature  may  be  briefly 
stated  as  follows : 


126  ORTHOPEDIC  SURGERY. 

The  distortion  occurs  chiefly  in  childhood  and  fully  develops  in 
adolescence.  In  the  earliest  types  there  is  an  habitual  distorted 
attitude  which  can  be  corrected  by  removing  the  superincumbent 
weight ;  in  the  later  forms  the  distortion  can  only  be  slightly  over- 
come by  removing  this  weight  and  in  the  most  severe  forms  no 
change  can  be  effected  in  this  way. 

It  remains,  therefore,  to  investigate  whether  the  anatomical 
changes  found  in  cases  of  the  severer  type  are  such  as  can  be 
caused  by  superincumbent  weight.  As  has  already  been  stated, 
these  changes  are  chiefly  a  twist  of  the  spinal  column,  with  such 
alterations  of  the  different  vertebrae  as  would  follow  such  a  twist, 
provided  the  bony  structures  were  unable  to  sustain  such  a  down- 
ward pressure.  To  demonstrate  that  superincumbent  weight  could 
cause  this  twist  the  following  experiments  were  tried. 

Observation  I.'  The  spinal  column  of  a  full-term  infant  was 
removed,  leaving  the  skin,  superimposed  muscles,  and  ligaments  in- 
tact, but  removing  the  ribs.  It  was  found  that  although  the  column 
was  more  flexible  than  in  children,  adolescents,  or  adults,  rotation 
was  not  readily  brought  about  by  simply  pressing  the  two  ends 
toward  each  other,  holding  each  end  in  the  hand ;  the  amount  of 
lateral  deviation,  that  is,  curving  sideways,  without  rotation  of  the 
bodies,  was  not  great,  though  much  greater  than  in  well-grown 
spinal  columns.  The  most  noticeable  effect  of  pressing  the  upper 
part  downward  was  to  cause  a  bending  with  the  concavity  forward; 
bending  with  the  concavity  backward  was  possible  only  to  a  com- 
paratively slight  degree.  Rotation  was  easily  produced  by  twisting 
the  spine. 

Observation  II.  The  body  of  a  young  female  adult  was  hung  by 
the  head  with  the  head  fixed  and  the  body  free  from  the  floor;  the 
skin  of  the  back  having  been  dissected  off,  long  pins  were  driven 
in  the  occiput  and  in  the  spinous  processes  of  the  different  verte- 
brae; a  thread  with  a  weight  was  hung  from  the  pin  in  the  occiput, 
long  enough  to  touch  the  floor,  and  a  second  thread  with  a  piece 
of  chalk  attached  was  hung  successively  from  the  pins  inserted  in 
the  different  spines  and  from  the  sacrum.  The  pelvis  was  then 
twisted  forcibly  and  the  arc  marked  off  on  the  floor  by  the  piece  of 
chalk,  as  suspended  from  the  different  pins,  was  measured  from 
that  point  in  the  circle  indicated  by  the  plumb  line,  hung  from  the 
pin  inserted  in  the  immovable  head. 

The  figures  are  as  follows,  measured  from  the  line  from  the  occi- 
put: 

^  The  writers  are  indebted  to  Prof.  Dwight    and  Drs.  Mixter,   Conant,  Newell,   and 
Burrell  of  the  Harvard  Medical  School  for  their  assistance  in  their  experiments. 


LATI'IRAL    CUA'VATUA'KS   ()/'    Till-:  S/>/NK.  127 

Arc  described  by  a  line  from  sacrum,  150" 

"          "           "           "           axis,  66' 

first  dorsal,  83^ 

third  dorsal,  100° 

sixth  dorsal,  1 18'-' 

"       .     "           "           twelfth  dorsal,  130^ 

third  lumbar,  136^ 

While  these  figures  are  only  approximate,  as  the  amount  of  force 
used  in  the  successive  twistings  was  not  measured  and  presumably 
not  the  same,  yet  they  indicate  that  the  amount  of  rotation  possi- 
ble is  greatest  in  the  dorsal  region,  leaving  out  of  account  the  twist- 
ing possible  in  the  atlo-axoid  articulation.  The  three  or  four  upper 
dorsal  vertebrae  moved  together;  the  greatest  rotation  appeared  to 
be  in  the  third  lower  dorsal;  lateral  deviation  (that  is,  without  rota- 
tion) was  possible  only  in  the  lower  dorsal  vertebrae.  Pressure 
made  on  the  floating  ribs  appeared  to  have  little  effect  in  twisting 
the  vertebrae,  but  pressure  on  the  thoracic  ribs  appeared  in  a  mea- 
sure to  affect  the  line  of  the  spinal  column.  Some  play  in  the  costo- 
vertebral articulation  existed,  but  beyond  that  point  pressure  ex- 
erted on  the  ribs  was  transmitted  to  the  column. 

Volkmann'  found  that  in  life  the  greatest  possible  twist  of  the 
whole  body,  including  that  occurring  in  the  hip  joints,  was  144°,  so 
that  the  figures  here  given  are  overstatements  of  the  possible  phy- 
siological limits  of  rotation.  This  is  also  somewhat  greater  than 
that  indicated  by  the  facets  of  the  disarticulated  vertebrae,  which 
would  show  that  if  the  joints  were  firm  there  would  be  absolutely 
no  rotation  in  the  lumbar  region,  little  in  the  cervical,  except  in 
the  atlo-axoid  articulation,  and  not  much  in  the  dorsal  region. 
A  certain  amount  of  laxity  in  the  articulation  allows  more  play 
than  would  be  supposed  by  the  structure  of  the  bones.  This  was 
evident  on  forcibly  twisting  the  cadaver. 

The  amount  of  forward  and  backward  motion  possible  in  an 
adult  is  much  less  than  would  be  supposed.  This  is  apparent  on 
inspection,  and  has  been  accurately  measured  by  Meyer.- 

Observation  III.  The  whole  spinal  column  of  an  adult  male,  a 
dissecting-room  subject,  was  taken,  including  a  portion  of  the 
pelvis,  and  the  base  of  the  cranium.  The  larger  muscles  were  re- 
moved, but  the  ligaments  and  smaller  muscles  were  kept.  The 
pelvic  sacrum  was  firmly  held  in  a  vice  and  a  box  was  secured  on 
the  cranium  by  passing  a  rod,  firmly  secured  to  the  box  down  into 
the  medullary  canal  of  the  cervical  vertebrae ;   the  box  was  then 

'  Virchow's  Archiv,  1872. 

^  "Die  Statik  und  Mechanikdes  Menschlichen  Knochengerustes,"  p.  210.     Virchow's 
Archiv,  Bd.  xxxv.,  page  225.    Ibid.,  Bd.  xxx\n.,  1S66,  page  144.    Ibid.,  xxx\-iii..  page  15. 


128  ORTHOPEDIC  SURGERY. 

secured  so  that  it  would  move  up  and  down,  but  not  laterally  ;^ 
weights  were  placed  in  the  box. 

It  was  found  that  the  spinal  column  could  bear  a  considerable 
weight  without  yielding  to  any  noticeable  extent.  As  the  amount 
was  increased  a  curvature  with  concavity  forward  was  seen,  which 
increased  as  the  weight  was  increased  up  to  eighty-four  pounds. 
No  rotation  of  the  vertebrae  was  observed  as  long  as  the  weight 
bore  down  directly,  but  rotation  of  the  lower  dorsal  and  lumbar 
region  was  seen  when  any  lateral  deviation  was  made  in  the  cervi- 
cal region;  the  amount  of  rotation  or  deviation  was,  however,  very 
small  as  compared  with  that  possible  in  children. 

None  of  these  experiments  approximately  reproduced  the  condi- 
tions to  be  found  in  life,  as  the  attachments  of  the  ribs  had  been 
severed  and  the  viscera  removed.  Furthermore,  the  spinal  column 
in  the  adult  is  much  less  flexible  than  that  of  a  child  or  adolescent, 
when  lateral  curvature  is  usually  observed. 

Observation  IV.  The  body  of  an  infant  of  a  year  was  prepared 
in  the  following  way:  The  thighs  were  amputated  near  the  hip- 
joints  and  the  pelvis  fixed  upon  the  remaining  stumps  and  secured 
by  means  of  nails  on  a  board,  long  pins  were  passed  laterally 
through  the  pelvis  and  secured  to  the  board  by  means  of  hooks, 
and  the  whole  pelvis  then  imbedded  in  plaster-of-Paris. 

The  board  to  which  the  body  was  secured  was  then  placed  on  a 
stand  with  four  upright  rods  attached  at  the  four  corners,  to  which 
rods  a  flat  board  was  attached  so  that  it  would  slide  smoothly  up 
and  down.  The  child's  trunk  therefore  was  placed  between  two 
boards,  one  being  fixed  and  the  other  pressing  down  upon  the 
child's  head.  To  keep  the  head  in  place  it  was  inserted  in  a  tightly- 
fitting  tin  cylinder  which  was  fastened  to  the  under  surface  of  the 
board.  Weight  placed  upon  the  upper  board  (sliding  as  it  did 
freely  upon  the  uprights)  brought  a  downward  pressure  upon  the 
child's  head  and  shoulders.  To  make  the  latter  more  even  a 
wooden  collar  was  placed  around  the  neck  resting  on  the  shoulders. 
Long  pins  were  then  inserted  in  the  spinous  processes  of  the  ver- 
tebra; so  that  rotation  could  be  more  readily  noticed.  To  check 
the  falling  forward  of  the  neck,  a  cord  was  placed  around  the  neck 
and  fastened  at  the  side  to  the  uprights,  acting  as  a  check,  just  as 
in  life  the  longer  muscles  of  the  back  would  act  in  keeping  the 
body  erect. 

Downward  pressure  upon  the  upper  board  caused  the  child's 
back  to  bend  backward  (convexity  backward).  When  carried  be- 
yond a  certain  point  the  column  would  bend  sideways  with  marked 
rotation,  with  the  changes  usually  noticed  in  the  ribs,  flattening  on 
the  side  of  the  concavity  and  projection  on  the  side  of  the  convex- 


LATERAL    CURVATURES   UE    77/ E  SPINE. 


129 


ity.  This  projection  was  most  marked  in  the  middle  and  upper 
dorsal  region,  but  the  amount  of  greatest  rotation  api)cared  to  be 
in  the  lower  doi'sal  regicjn.  If  the  angle  of  downward  pressure  was 
changed,  or  if  the  pelvis  was  tipped  so  as  to  cause  a  curve  in  the 
spinal  column,  the  effect  of  downward  pressure  was  more  marked. 
Rotation  of  the  vertebrae  was,  of  course,  readily  produced  by 
lateral  pressure  twisting  the  spine;  and  on  removing  all  downward 
pressure,  by  placing  the  cadaver  in  a  horizontal  position  rotation 


Fig.  145. — Experiment  to  Demonstrate  Causation  of  Lateral  Cur\-ature. 

and  curvature  in  the  dorsal  region  was  easily  made  by  twisting  the 
pelvis  and  holding  the  head  fixed,  or  vice  versa,  the  axis  of  the  head 
and  pelvis  being  kept  the  same. 

Although  a  well-marked  scoliosis  was  thus  artificially  produced, 
attended  by  the  characteristic  flattening  of  the  ribs  on  the  side  of 
the  concavity  and  projection  on  that  of  the  convexity,  yet  a  more 
careful  examination  appeared  to  show  that  although  this  was  the 
result  of  downward  pressure,  it  was  downward  pressure  not  exerted 
in  a  perfectly  vertical  direction  ;  for  although  the  force  was  applied 
properly,  yet  it  was  not  possible  to  prevent  some  play  in  the  cervi- 
9 


I30 


ORTHOPEDIC  SURGERY. 


ilii 


cal  region,  from  which  it  resulted  that  the  force  fell  obliquely 
upon  the  under  portion  of  the  spinal  column,  causing  curvature 
and  necessarily  rotation. 

The  accompanying  illustration  indicates  the  lateral  curvature 
produced  in  the  experiment.     It  is  drawn  from  a  photograph. 

The  photograph  of  a  case  of  lateral  curvature  in  a  grown  child 
shows  the  similarity  of  the  shape  of  the  back  in  true  lateral  curva- 
ture to  that  of  the  experiment. 

If  it  were  practicable  to  apply  a  force  directly  downward  and 
-^.  transmit  it    through  the  cervical 

and  upper  dorsal  region  without 
deviation,  the  effect  upon  the 
lower  dorsal  region  would  be  to 
cause  an  antero-posterior  curva- 
ture. 

The  lateral  curvature  therefore 
results  from  downward  pressure, 
but  downward  pressure  applied 
obliquely  upon  some  portion  of 
the  spinal  column.  Rotation  fol- 
lows from  the  anatomical  struc- 
ture of  the  interlocked  vertebrae, 
it  being  possible  for  them  to  ro- 
tate slightly,  while  the  amount  of 
tipping  sideways  (without  twist- 
ing) which  the  articular  facets 
permit  is  much  less. 

Rotation  takes  place  with  the 
vertebral  bodies  directed  toward 
the  convexity  and  the  spine  to 
the  concavity  for  the  reason  that 
the  former  being  larger,  are  un- 
able to  be  crowded  into  the 
smaller  space  of  the  concavity,  and  are  pushed  in  the  direction 
where  there  is  more  space.  Perhaps  also,  as  has  been  pointed  out 
by  Judson,  the  fact  that  the  bodies  are  free  while  the  spines  are 
held  by  muscles  may  give  the  former  more  freedom  in  movement. 

From  the  above  facts  the  following  generalizations  may  be 
made :. 

The  effect  of  the  weight  of  the  thorax  on  head  and  shoulders 
would  be,  if  applied  in  a  vertical  direction,  to  bend  the  spinal 
column  forward  and  backward,  but  in  flexible  spines  the  superin- 
cumbent weight  rarely  falls  directly,  and  curvature  follows.  This 
is  at  first  a  physiological  process,  but  it  subsequently  becomes,  by 


=  £ 


Fig.  146. — Dorsal  Right  Convex  Curve. 


LATERAL    CURVATURES   OF    77//';  SI'fNE.  13  r 

the  alteration  in  the  shapes  of  the  bones  under  altered  pressure,  a 
pathological  change. 

The  extent  of  th-e  curvature,  and  the  situation  of  the  curve  w  ill  be 
determined  by  the  attitude  habitually  taken  by  the  individual,  and 
perhaps  also  by  a  difference  in  the  resisting  power  in  different  parts 
of  the  column. 

The  injurious  effect  of  superincumbent  weight  in  curving  the 
spine,  is  increased  by  the  obliquity  of  the  pelvis,  or  the  inclination 
of  the  shoulders  so  frequently  taken  by  persons  of  weak  muscular 
systems  in  sitting  sideways  and  leaning.  The  curve  is  usually  in 
the  dorsal  region,  with  the  right  shoulder  raised,  as  the  majority  of 
people  are  right-handed. 

The  distortion  is  one  of  growing  years,  and  is  more  common  in 
girls  than  boys,  for  two  reasons,  namely,  that  at  the  age  when 
lateral  curvature  is  usually  seen  first,  girls  grow  more  rapidly  than 
boys,  and  their  muscular  system  is  less  well  developed,  from  the 
customary  life  habits  of  girls  in  society.  The  effect  of  superin- 
cumbent weight  upon  a  yielding  spine  in  adult  life,  after  the  verte- 
brae have  ceased  to  grow,  is  to  cause  an  increase  in  the  antero- 
posterior curve  O'f  the  back. 

The  lack  of  normal  resistance  of  the  bony  structures  of  the  spinal 
column,  in  part  or  in  whole,  may  be  supposed  to  exist  in  certain 
individuals  without  the  supposition  of  any  pathological  change  of 
sufificient  gravity  to  be  classed  as  rickets.  During  the  age  of 
growth,  complete  ossification  of  the  different  vertebrse  has  not 
been  attained.  It  is  well  known  in  certain  cases,  that  in  rapidly 
growing  persons,  the  ossification  of  the  spine  does  not  make  equal 
progress  with  the  ossification  elsewhere. 

Alexander  Shaw  mentions  two  preparations  of  the  spine  in  the 
Museum  of  the  Middlesex  Hospital,  where  such  a  condition  of 
things  exist  (vide  Holmes's  "  System  of  Surgery,"  Vol.  HI.,  Ameri- 
can Edition). 

An  analogue  of  this  condition  is  found  in  the  knock-knee  de- 
veloping about  the  time  of  puberty,  and  the  accompanying  cut 
from  the  Warren  Museum  may  serve  as  an  illustration.  This  view 
would  be  supported  by  Vogt,  who  calls  attention  to  the  fact  that 
the  development  of  ordinary  lateral  curvature  comes  at  periods 
of  the  physiological  increase  of  the  process  of  ossification  of 
the  whole  skeleton.  Vogt  describes  three  periods  of  increase  of 
growth:  ist,  includes  the  first  two  years;  2d,  the  beginning  of  the 
second  dentition  in  the  seventh  year  to  the  approach  of  the  time 
of  puberty;  3d,  the  period  of  puberty.  Fisher  writes  that  atten- 
.  tion  should  be  especially  directed  to  the  fact  that  mere  constant 
bending  of  the  spine  to  one  side  will  not  induce  a  structural  change; 


132 


ORTHOPEDIC  SURGERY. 


Fig.  147.— Rhachitic  Lateral  Curvature  of  Spine.    From  Specimen  in  the  Warren  Museum. 


LATERAL    CURVATURES   ()!■     THE  S/'/NE.  [33 

that  there  must  exist,  also,  within  the  column  itself,  some  con- 
tributory defect,  without  which  lateral  curvature  will  not  become 
developed. 

Adams  and  Fisher  believe  that  this  contributory  defect  is  in  the 
structural  relaxation  or  weakness  of  the  ligaments,  rather  than  in  a 
lack  of  resistance  of  the  bones,  Fisher,  however,  himself  com- 
pares the  condition  to  that  seen  in  knock-knee,  which  is  now  gen- 
erally regarded  to  be  due  to  an  osseous  rather  than  a  ligamen- 
tous defect. 

The  constitutional  influence  in  the  development  of  lateral  curva- 
ture is  little  understood.  Drachmann  found  that  only  a  small  por- 
tion of  the  anaemic  and  scrofulous  children  in  the  28,000  scholars 
examined  were  scoliotic.  An  hereditary  predisposition  to  spinal 
curvature  frequently  co-existing  with  a  consumptive  tendency,  is 
mentioned  by  Adams  as  occurring  in  girls  from  seven  to  twelve 
years  of  age  or  later;  and  in  those  cases  the  curvature  tends  to  in- 
crease rapidly  and  terminate  in  a  conspicuous  deformity;  but  lateral 
curvature  of  the  spine  according  to  Adams  rarely  co-exists  with 
consumption.  Eulenburg  found  25  per  cent  of  scoliotic  patients 
showed  some  hereditary  tendency  toward  the  affection.  Vogt 
found  it  in  one-half  of  his  cases.  While  Rupprecht '  considers  ordi- 
nary lateral  curvature  as  rhachitic,  Lorenz  thinks  that  weakly  chil- 
dren have  ipso  facto  a  disposition  to  lateral  curvature;  but  he  is 
unwilling  to  say  that  in  cases  where  it  occurs  the  children  are 
always  rhachitic ;  for  the  lack  of  resistance  of  a  rapidly-growing  bone 
may  be  sufificient,  under  certain  static  conditions,  to  develop  the 
lateral  distortion. 

It  has  already  been  said  that  the  most  common  curve  is  that 
which  raises  the  right  shoulder  and  causes  a  convexity  in  the  mid- 
dle dorsal  region  to  the  right ;  but  the  most  rational  explanation  of 
this  fact  may  be  found  in  the  usual  habit  of  greater  use  of  the  right 
arm. 

In  the  case  noted  of  two  girls  (twin  sisters)  who  sat  at  the  same 
bench  at  school  and  leaned  habitually  one  on  the  right  arm,  the 
other  on  the  left,  curvatures  were  developed  in  opposite  directions. 

Sigfried  Levy^  thinks  that  there  are  two  distinct  etiological  fac- 
tors in  the  production  of  habitual  scoliosis:  one,  "  an  anomaly  of 
nutrition,"  a  purely  organic  matter;  secondly,  certain  mechanical 
causes — faulty  positions  of  standing  and  sitting.  Neither  one  of  the 
factors  can  cause  it  alone;  both  must  be  present  at  the  same  time. 
In  support  of  this  view,  he  speaks  of  a  case  which  he  saw,  where  a 
girl  of  three  years  had  a  resection  of  the  knee,  and  grew  up  with 

'  V.  Centralb.  f.  orthop.  Chir.,  1SS6,  2. 

=  Also  Busch,  Berl.  Klin.  Wochenschrift,  iSSo,  p.  106,  vol.  i. 


134 


OR  THOPEDIC  S  URGER  Y. 


one  leg  nine  centimetres  shorter  than  the  other.  The  pelvis  was 
always  tilted,  but  there  was  no  suspicion  of  scoliosis  until  she  was 
twelve  years  old,  when  she  began  to  have  headache,  pain  in  the 
side,  malaise,  etc.,  and  in  spite  of  all  precautions,  a  typical  lateral 
curvature  rapidly  developed.  He  has  seen  three  other  such  cases; 
and  in  over  a  hundred  cases  of  habitual  scoliosis  which  he  has  ob- 
served, in  every  case  symptoms  of  general  disturbance  (as  in  the 
case  related  above)  accompanied  the  development  of  the  deformity. 
As  is  well  stated  by  Fisher,  the  causes  of  lateral  curvature  are 
the  predisposing  and  the  proximate. 

1.  Predisposing  causes,  which  are  constitutional,  such  as  debility, 
rickets. 

2.  Proximate  causes  (essentially  local),  which  disturb  the  equilib- 
rium. These  are  vicious  positions,  sitting  positions,  faulty  atti- 
tudes, empyema,  or  any  long-continued  irregular  distribution  of 
weight. 

Pathology. 

The  pathological  changes  in  true  lateral  curvature  are  not  those 
resulting  from  any  disease  of  the  vertebra,  but  simply  the  altera- 
tions of  bone  yielding  under  pressure  in  an  abnormal  direction. 

The  changes  are  chiefly  to  be  noticed  in  the  spinal  column,  viz., 
the  bodies  of  the  vertebrse,  the  articulating  processes,  and  the 
spines;  but  in  severe  cases  all  the  bones  of  the  trunk  may  be 
altered  and  also  the  pelvis.  The  muscles  and  ligaments  are  altered 
in  their  tonicity  and  length,  and  internal  organs  may  be  displaced. 

The  changes  seen  necessarily  vary  according  to  the  stage  of  the 
a;fTection  and  the  degree  to  which  the  deformity  has  developed ; 
and  consist  chiefly  of  a  curvature  and  a  torsion. 

In  the  flexible  stage  of  scoliosis  no  anatomical  change  will  be 
found  in  the  bones,  ligaments,  or  muscles;  but  in  the  stage  of  fixed 
curves,  and  in  the  latest  phases  of  the  affection,  marked  distortion 
of  the  vertebral  bodies  is  to  be  observed. 

Wherever  a  lateral  curve  of  the  spine  has  taken  place,  the  sides 
of  the  bodies  are  crowded  together  on  the  concave  side  and  sepa- 
rated on  the  convex  side  of  the  curve.  Growing  bone  adapts  itself 
to  altered  pressure,  and  in  time  the  bones  of  the  convex  side  will 
grow  more  than  on  the  concave  side  and  the  vertebral  bodies  will 
be  found  misshapen,  thicker  on  one  side  than  the  other;  and  changes 
in  the  shape  of  the  articulating  and  transverse  processes  will  also 
take  place.  As  has  already  been  stated,  a  twist  takes  place  in  the 
spinal  column  and  consequently  the  transverse  processes  are  out 
of  the  normal  plane ;  the  ribs  follow  the  transverse  processes,  and  a 


LATERAL    CURVATURES   OE    'THE  S/'/NE. 


135 


characteristic  projection  on  one  side  and  flattening  on  the  other 
occur. 

If  the  cokimn  is  curved  laterally  in  two  or  three  directions,  rota- 
tion necessarily  takes  place  in  different  parts  of  it  in  opposite  direc- 
tions, and  the  projection  of  the  ribs  is  naturally  more  noticeable 
than  the  projection  of  the  transverse  processes  without  ribs;  but 
in  the  latter  case  the  lumbar  muscles  are  thrown  forward,  or  recede, 
giving  a  characteristic  alteration  in  the  contour  of  the  trunk. 

The  inter-vertebral  cartilages  necessarily  twist  with  the  vertebrae 
and  are  compressed  on  one  side  more  than  on  the  other  in  cases  of 
marked  curves;  but  in  severe  cases  they  will  be  found  on  measure- 


FiG.  148. — Torsion  in  Lateral  Curvature. 


Fig.  149. — Torsion  in  Lateral  Curvature. 


ment  thicker  on  the  side  of  convexity  than  of  concavity,  so  that 
instead  of  being  flat,  they  are  wedge-shaped,  from  side  to  side. 

In  some  cases,  as  has  been  shown  by  Adams  and  others,  the  tips 
of  the  spines  in  severely  rotated  columns  may  be  on  a  straight  line, 
while  the  bodies  are  badly  distorted,  the  axis  of  rotation  being 
near  the  spinous  processes. 

For  an  understanding  of  this  torsion,  it  is  Avell  to  bear  in  mind 
that  the  structure  of  the  spinal  column  is  such  that  a  bending  to 
the  side  without  any  twisting  of  the  column  is  only  possible  to  a 
limited  extent.  The  pure  sidewise  motion  of  the  column,  the  only 
motion  possible  in  fish,  is  fully  developed  in  reptiles  and  in  some 
animals,  but  is  limited  in  man.  In  old  people  it  may  be  almost 
wanting,  though  in  foetal  life  and  in  infants  it  is  much  more  free. 


136 


ORTHOPEDIC  SURGERY. 


A  detailed  anatomical  description  of  the  structure  of  the  verte- 
brae is  hardly  necessary  for  an  understanding  of  the  phenomenon 
of  torsion. 

The  individual  vertebrae  rotate  on  each  other  to  a  limited  extent; 
the  amount  of  possible  rotation  varying  according  to  age,  and  the 
condition  of  the  spine.  The  various  parts  of  the  spinal  column 
permit  a  different  amount  of  rotation ;  the  upper  cervical  region 
permitting  the  most,  and  the  lumbar  region  the  least. 

Where  the  demands  of  the 
individual  require  more  mo- 
tion to  the  side  than  would  be 
possible  by  the  purely  side- 
way  bending  of  the  column, 
this  can  be  gained  by  a  tor- 
sion of- the  column  so  that  the 


Fig.  151. 


freer  antero-posterior  movement  of  it  may  aid  the  limited  side 
motion. 

Some  discussion  has  taken  place  as  to  whether  the  torsion  is 
primary  to  the  curve  or  secondary.  ^z^xxmAt  {Centralblatt  f.  Chir., 
Nov.  nth,  '82)  is  of  the  opinion  that  the  torsion  is  primary,  as 
there  is  always  a  curvature  if  torsion  exists,  but  slight  curvature 
may  take  place  without  torsion. 

Dr.  Judson's  excellent  experiment  to  demonstrate  the  phenome- 
non of  rotation  is  well  known,  and  can  be  understood  by  a  glance 
at  the  accompanying  illustrations  (Figs.  150,  151).'   A  flexible  rod  is 


LATERAL    CURVATURES   (>/'     '/'//A'  SJ'JNE. 


137 


passed  through  the  disarticulcd  vertebra;  of  a  spinal  column,  placed 
in  their  normal  order,  one  above  another,  and  kept  in  relative 
position  by  means  of  elastic  straps,  secured  to  uprights.  Increase 
of  downward  pressure  demonstrates  rotation  and  lateral  curvature. 

There  is,  therefore,  necessarily  a  torsion  of  the  spinal  column, 
whenever  it  is  bent  toward  the  side  to  any  considerable  extent ; 
and  when  a  curved  condition  of  the  spine  becomes  habitual  or  con- 
stant the  changed  pressure  in  the  spinal  column  produces  in  time 
alterations  in  the  shape  of  the  vertebral  bodies,  and  in  the  articulat- 
ing surfaces. 

Lorenz  has  clearly  shown  that  not  only  do  the  bodies  of  the  ver- 
tebrae give  evidence  of  torsion  around  the  axis  of  the  spinal  column, 
but  there  is,  in  advanced  cases,  evidence  of  torsion  of  the  bodies 
themselves  in  oblique  and  spinal  -longitudinal  striations  on  the 
bodies  in  the  place  of  the  usual  vertical  marking.  Besides  the 
rotation,  as  has  been  stated,  the  bodies  grow  in  the  direction  of  the 
least  pressure;  consequently  the  bodies  lose  their  normal  symmet- 
rical shape;  the  spinal  canal  becomes  irregularly  oval  in  shape,  and 
the  transverse  and  articular  processes  are  altered  according  to  the 
position  of  the  vertebrae;  those  on  the  crowded  side  being  broader 
and  lower  than  on  the  convex  side.  The  shape  of  the  vertebrae  is 
indicated  in  the  accompanying  picture,  but  it  must  be  borne  in 
mind  that  the  vertebrae  vary  necessarily  according  to  their  relative 
position  in  the  curve  and  the  direction  in  which  they  receive  the 
superincumbent  pressure. 

The  alterations  of  the  bones  in  the  vertebral  column  are  not  to 
be  studied  in  the  individual  vertebrae.  The  whole  column  is  twisted 
and  all  the  bones  are  necessarily  altered  according  to  the  abnormal 
positions,  as  a  result  of  those  atrophic  changes  in  bone  which 
always  result  from  abnormal  pressure  or  Aveight  bearing. 

The  ribs  are  not  only  rotated,  but  altered  in  shape,  as  is  seen 
in  the  accompanying  picture.  They  are  also  altered  in  the  line  of 
their  obliquity,  being  lowered  on  the  side  of  the  concavity  of  the 
curve. 

The  contour  of  the  thorax  is  changed  from  the  altered  shape  of 
the  ribs,  and  the  clavicles  remain  unchanged ;  but  the  tip  of  the 
sternum  may  be  deflected  from  the  median  line.  The  ribs  project 
backward  at  the  angle  on  the  side  of  the  convexity  of  the  curve 
and  forward  in  the  line  of  the  concavity. 

A  cross  section  of  the  thorax  shows  an  alteration  of  the  diagonal 
axes  of  the  spine,  which  should  normall}'  be  equal,  but  in  the  ordi- 
nary dorsal  right  convex  curve  the  diagonal  axis,  from  the  left 
front  side  to  the  right  back  side  of  the  thorax,  is  longer  than  the 
other. 


138 


ORTHOPEDIC  SURGERY. 


The  different  halves  of  the  thorax,  on  cross  section,  should  be 
symmetrical  normally,  but  in  lateral  curvature  the  portion  on  the 


Tig.  152. — Individual  Vertebra  Altered  in  Lateral  Curvature. 


mm 


Fig.  154. — Individual  Vertebra  Altered  in' 
Lateral  Curvature. 


y^/ 


Fig.  155.     Torsion  in  Lateral  Curvature. 


Fig.  153. — Change  in  Shape  of  Bodies  of 
Vertebras. 


Fig.  156. — Torsion  and  Curvature  in 
Lateral  Curvature. 


convex  side  of  the  line  from  the  spine  to  the  sternum  is  smaller 
than  that  on  the  concave  side,  owing  to  the  flattening  of  the  ribs. 
The  vertebral  bodies  are  also  crowded  into  this  half  of  the  thorax, 


LATERAL    CURVATURICS   Ol'     77/ A'  S/'/N/C. 


139 


so  that  there  is  less  ro(MTi  for  expansion  of  the  lun^  on  that  side 
than  on  the  other  side. 

In  the  severest  cases  of  distortion,  the  lower  ribs  on  one  side 
niay  rest  upon  the  crest  of  the  ilium  or  even  sink  into  the  pelvic 
cavity,  and  an  alteration  of  the  shape  of  the  pelvis  may  be  caused 
in  this  way. 

The  muscles  of  the  spinal  column  in  an  early  case  of  lateral 
curvature  are  unaffected,  excefit  in  cases  of  a  purel}'  paralytic 
nature. 

Adams  found  in  dissections  of  advanced  cases  that  the  muscles 
on  both  sides  of  the  spine  "  were  much  wasted,  reduced  to  very 
thin  layers,  pale  in  color,  and  in  more  or  less  advanced  stages  of 
fatty  degeneration,  which  probably  commences  in  the  muscles  in 


Fig.  157. — Alteration  in  Angle  of  Ribs 
in  Lateral  Curvature. 


Fig.  15S.— Distortion  of  Ribs  and  Thora.x  in  Lateral 
Curvature. 


the  concavity  of  the  curve,  those  on  the  convexity  wasting  at  a 
much  later  period."  (The  muscles  in  the  concavity  of  the  curve 
are  found  neither  prominent  nor  rigid.) 

In  advanced  cases  of  lateral  curvatures,  the  ligaments  on  the 
concave  side  of  the  spinal  column  are  shortened  and  those  on  the 
convex  side  are  elongated.  This  is  the  result  of  adaptive  shorten- 
ing of  them,  and  is  not  found  in  the  early  stages  of  the  affection. 

Distortion  of  the  Pelvis  in  Cases  of  Lateral  Curvature  of  the  Spine. 
— The  pelvis  is  not  distorted  in  lateral  curvature  of  the  spine  ex- 
cept in  cases  of  general  rickets,  for,  as  a  rule,  obliquity  of  the  pelvis 
does  not  exist  in  lateral  curvature.  The  pelvis,  however,  assumes 
the  position  of  obliquity  from  a  prominence  of  one  hip  due  to  the 
uncovering  of  the  crest  of  the  ilium  by  the  over-projecting  ribs. 

Where  there  is  irregularity  in  the  length  of  the  legs,  obliquity  of 


I40 


ORTHOPEDIC  SURGERY. 


the  pelvis  necessarily  exists.  The  prominence  and  rigidity  of  the 
spinal  muscles  in  the  lumbar  region  frequently  seen  on  the  con- 
vexity of  the  sharp  lumbar  curve  often  conveys  to  the  touch  a 
doubtful  sense  of  fluctuation,  and  is  frequently  laid  to  the  suspicion 
of  an  abscess.  The  spinal  cord  is  not  affected  by  lateral  curvature. 
The  spinal  nerves  in   consequence  of  the  large  size  of  the  fora- 


Fig.  15-5  — Displacement  of  Ribs  in  Lateral 
Curvature. 


Fig.  160. — Distortion  of  Ribs  in  Lateral  Curvature^ 


Fig.  161. — Distorted  Pelvis  in  Lateral  Curvature. 


Fig.  162. — Scoliotic  Pelvis. 


mina  are  not  liable  to  suffer  compression  except  in  cases  of  great 
severity. 

Infliience  of  Lateral  Curvature  in  Caiising  Displacement  of  Abdom- 
inal Viscera. — The  abdominal  viscera  are  less  likely  to  be  displaced, 
even  in  severe  cases,  than  the  thoracic  organs,  though  the  liver 
may  be  out  of  place  and  altered  in  form,  according  to  the  direction 
and  extent  of  the  spinal  distortion. 

The  spleen  may  suffer  some  compression,  and  the  aorta  is  neces- 


LATERAL    CURVATUKJ'IS  OF    11  IE  S/'/jVE. 


J41 


sarily  di.spkvced ;  tlic  thoracic  cavity  on  the  side  of  tlie  convexity 
of  the  curve  is  flattened,  and  diininislied  in  size  to  a  much  larger 
extent  than  on  the  concavity  in  consequence  of  the  flattening  of 
the  ribs  on  the  convexity  of  the  curve. 

Adams  reports  a  case  where  at  a  2)ost-mortem  examination,  he 
was  barely  able  to  pass  the  hand  between  the  bodies  of  the  verte- 
brae and  the  ribs.  The  lung  on  the  convexity  of  the  curve  is, 
therefore,  much  more  compressed  and  flattened,  and  the  thoracic 
cavity  on  the  concavity  of  the  curve  is  always  found  to  be  much 
larger  than  would  be  expected.  The  lung  on  the  concavity  of  the 
curve  may  be  altered  in  form,  but  is  not  diminished  in  bulk  as  on 
the  side  of  convexity.  The  heart  is  generally  found  displaced 
toward  the  concavity  of  the  curve  in  severe  cases. 

Adams  claims  that  consumption  or  a  consumptive  tendency  fre- 
quently exists  as  a  complication  of  lateral  curvature  of  the  spine; 
but  he  admits  that  he  has  no  statistics  to  support  this  view,  and  it 
is  not  in  accordance  with  the  experience  of  physicians  who  make 
a  specialty  of  diseases  of  the  lungs,  who  claim  that  they  rarely  find 
cases  of  consumption  in  patients  with  lateral  curvature. 

Diagnosis. 

A  diagnosis  of  lateral  curvature,  in  a  severe  case,  is  so  simple 
that  an  inspection  of  the  patient  is  all  that  is  required. 

In  the  less-marked  cases,  however,  the  recognition  of  the  true 
nature  of  the  deformity  is  not  so  easy,  and  a  careful  examination  is 
necessary,  not  only  for  the  exclusion  of  other  affections  of  the 
spine,  but  also  for  an  insight  into  the  stage  and  progress  of  the 
lateral  curvature,  and  the  amount  of  rotation  and  bony  change  in 
the  spinal  column. 

The  method  of  examination  of  a  case  of  lateral  curvature  is  as 
follows : 

The  patient's  back  should  be  bared  to  the  level  of  the  trochan- 
ters, and  the  arms  should  be  allowed  to  hang  free.  The  most 
natural  attitude  in  standing  should  be  noted  and  also  the  position 
of  the  patient  in  an  attempt  to  stand  in  as  straight  a  position  as  is 
possible;  the  tips  of  the  spinous  processes  are  to  be  marked  with  a 
crayon  and  also  the  ends  of  the  scapula.  To  determine  the  central 
line  a  string,  to  which  a  slight  weight  is  attached,  is  hung  from 
the  seventh  cervical  vertebra  (to  which  it  can  be  fixed  by  a  piece 
of  adhesive  plaster),  the  string  being  long  enough  to  hang  to  the 
cleft  of  the  buttock.  The  distance  of  the  tips  of  the  scapulae  (the 
arms  being  crossed  in  front  of  the  chest)  from  this  central  line 
should  be  measured,  and  also  the  distances  from  this  line  to  the  points 


142 


ORTHOPEDIC  SURGERY. 


of  greatest  curvatur.e  ®f  tke  line  of  the  spinous  process.  These  points 
being  noted,  the  slop©  of  the  shoulders,  the  outlines  of  the  sides  of 
the  trunk,  and  the  contour  of  the  back,  as  well  as  any  lack  of 
symmetry  orunilateral  fulness,  should  be  carefully  recorded,  both 

when  the  patient  is  standing  and  in 
the  stooping  position,  with  the  back 
well  arched.     If  a  devi4tion  of  the  line 


Fig.  163. — Torsion  of  Ribs  in  Lateral  Curvature. 


Fig.  \t 


-Projection  of  Ribs  seen  in  a  Stoopinc 
Position  of  Back. 


of  the  spinous  processes  is  observed,  a  lack  of  symmetry  of  outline, 
or  a  unilateral  projection  of  the  ribs  or  scapulae,  in  the  erect  posi- 
tion, the  patient  should  be  suspended  by  means  of  a  head  sling  and 
also  made  to  lie  in  a  recumbent  position  upon  the  face.     A  marked 

alteration  of  the  curvature, 
contour,  or  outlines  follow- 
ing removal  of  the  superin- 
cumbent weight  is  of  parti- 
cular importance. 

The  inspection  of  the 
arched  back,  stooping  from 
a  sitting  position  is  import- 
ant ;  any  rotation  of  the 
fixed  ribs  due  to  osseous 
change  is  easily  detected  in 
the  lack  of  symmetry  and 
projection  of  one  side  more 
than  the  ®ther. 

The  flexibility  of  the  spine 
should  be  tested  by  causing  the  patient  to  stand  first  with  one  foot, 
and  then  the  other  upon  a  series  of  blocks  half  an  inch  in  thick- 
ness, anci  testing  what  height  can  be  placed  under  the  patient's  foot 
without  preventing  her  from  standing  upon  both  legs  with  the  limbs 
straight  and  without  flexion  at  the  knee;    this  tests  the  lateral  flex- 


FiG.  165.— Projection  of  Side  of  Thorax  in  Lateral  Curva- 
ture, seen  when  Back  is  Bent. 


■     LATERAL    CURVATURI'lS   UF    THE  SJ'LVE.  143 

ibility  in  the  lower  part  of  the  spinal  column,  in  testing  the  flex- 
ibility higher  up,  the  patient  should  be  seated  on  a  stool,  and  one 
hand  of  an  assistant  be  placed  upon  her  side,  above  the  crest  of 
the  ilium,  while  the  other  hand  should  be  placed  upon  the  crest  of 
the  ilium.  The  patient  should  then  be  directed  to  bend  sideways 
toward  the  side  of  the  higher  hand,  and  the  amount  of  this  motion, 
without  tilting  of  the  pelvis,  is  to  be  noted. 

The  lateral  flexibility  can  be  often  readily  seen  by  directing  the 
patient  to  bend  to  one  side,  keeping  the  legs  straight  and  avoiding 
twisting  the  pelvis. 

The  amount  of  possible  rotation  of  the  spine  may  also  be  of  im- 
portance ;  in  which  case  the  patient  should  sit  upon  a  revolving 
stool  with  the  shoulders  held  firmly  by  an  assistant,  when  the 
amount  of  possible  revolution  of  the  stool  in  one  direction  or  an- 
other, without  turning  the  shoulders,  can  be  approximately  esti- 
mated. 

It  is  not  always  necessary  to  examine  the  front  of  the  patient's 


Fig.  166.— Diagram  of  Normal  Thorax,  Fig.  167.— Diagram  of  Thorax,  Lateral 

seen  from  Above.  Curvature,  seen  from  Above. 

trunk.  When  this  is  done,  the  projection  of  the  ribs  in  front;  and 
the  difference  in  the  prominence  or  flatness  of  the  two  breasts,  the 
deviation  of  the  tip  of  the  sternum  and  of  the  umbilicus  from  the 
median  line  are  of  importance,  as  indicating  the  amount  of  struc- 
tural change  which  had  taken  place. 

The  strength  of  the  muscles  of  the  patient's  back  may  be  tested 
by  means  of  a  dynamometer,  or  spring  balance,  and  the  height 
and  weight  should  be  recorded  and  compared  with  the  normal 
standard  for  the  age  as  given. 

A  diagnosis  of  lateral  curvature  in  the  early  stage  is  to  be  made 
on  the  habitual  lack  of  symmetry  in  the  outline  of  the  sides  of  the 
trunk,  the  slope  of  the  shoulders,  or  contour  of  the  back,  in  the 
unnatural  projection  of  one  shoulder  blade  or  of  one  hip;  and  on 
a  constant  deviation  of  the  line  of  the  spinous  processes  from  the 
vertical  line. 

An  accidental  assumption  of  any  position  with  the  prominence 
of  these  symptoms  does  not  necessarily  constitute  lateral  curva- 
ture; but  the  constant  habitual  assumption  of  such  a  position  when 
the  patient  stands  in  the  attitude  of   ease  and   greatest  comfort 


144 


ORTHOPEDIC  SURGERY. 


must  be  regarded  as  a  lateral  curvature  either  of  a  flexible  or  fixed 
type. 

Adam's  and  Fisher  claim  that  a  distinction  should  be  made  be- 
tween  deviations  and  curvatures  of  the  spinal  column,  and  state 

that  much  of  the  confusion  regarding 
causation  and  the  results  of  treatment 
is  from  a  lack  of  this  important  dis- 
tinction. This  distinction,  however,  is 
not  always  a  practical  one,  as  in  the 
early  stage  of  lateral  curvature  before 
fixation  has  occurred  permanent  rota- 
tion is  not  always  recognizable.  Mr. 
Fisher  figures  three  cases  of  so-called 
curvature  of  the  spine;  and  only  one 
of  these,  he  claims,  is  a  curvature  of 
the  spine,  the  two  others  being  devia- 
tions of  the  spinal  column.  In  a  cur- 
vature of  the  spine  he  considers  that 
there  is  rotation  of  the  bodies  of  the 
vertebrae,  whereas  in  a  deviation  of  the 
spinal  column  there  is  no  rotation.  He 
suggests  the  term,  lateral  bending,  for 
a  class  of  cases  which  occur  in  young 
girls  who  are  overworked  and  under- 
fed, the  servants  of  the  lower  classes, 
girls  educated  at  "  cheap  establish- 
ments for  young  ladies,"  those  working 
in  the  second-rate  drapery  shops,  and 
so  forth ;  it  is  also  met  with  in  those 
who  have  suffered  from  long  illness 
of  an  exhausting  nature,  and  in  those 
affected  with  that  defective  condition 
of  health  commonly  described  as  gen- 
eral debility. 

Frequently  accompanying  this  de- 
formity is  that  mental  condition  which 
tends  to  exaggerate  any  bodily  de- 
rangements. The  hysterical  complica 
tion  generally  appears  at  a  late,  and 
not  at  an  early,  stage  of  the  affection,  which  must  not  be  con- 
founded with  the  so-called  "  hysterical  spine." 

The  amount  of  fixed  rotation  is  best  indicated  by  the  amount  of 
unilateral  projection  of  the  ribs  at  the  level  of  the  shoulder  or  in  the 
hollow  of  the  back  when  the  patient  bends  forward  or  is  recumbent. 


Fig. 


-Lumbar  Flexibility  of  the  Spine. 


LATERAL    CURVATURES   OF    THE  SPINE. 


H5 


The  amount  of  osseous  and  ligamentous  change  is  in  proportion 
to  the  change  in  the  amount  of  the  curves  and  asymmetrical  symp- 
toms, as  the  patient  lies  or  is  suspended. 

In  this  way  it  is  possible  to  determine  the  amount  of  progress 
the  distortion  has  made,  and  the  stage  of  the  affection. 

A  notable  error  in  the  diagnosis  of  lateral  curvature  is  recorded 
by  Mr.  Adams  in  the  practice  of  surgeons  of  the  last  generation, 
which  seems  hardly  possible  at  the  present  time.  The  relaxed 
muscles  in  the  lumbar  region  in  a  case  of  severe  lateral  curvature 
were  mistaken   for  a  deep  abscess,  and    operative   measures  were 


Fig.  169. — Lateral  Flexibility  of  '1  runk 


Fig.  170. — Lateral  Flexibility  of  Trunk. 


advised  by  several  surgeons  of  prominence.  The  subsequent  re- 
sult proved  the  swelling  to  be  purely  the  deep  muscular  tissue  in 
the  loin  made  prominent  by  the  rotated  transverse  vertebrse  on  the 
convexity  of  a  lumbar  curve. 

The  writers  can  record  a  large  dorsal  lateral  curve  with  severe 
rotation  of  the  ribs  which  was  mistaken  by  a  physician  (a  skilled 
specialist  in  diseases  of  the  chest)  for  an  obscure  form  of  pleural 
effusion. 

Lateral  curvature  is  not  infrequently  confounded  with  caries  of 
spine  through  simple  ignorance  of  the  nature  of  either  affection, 
both  being  classed  as  chronic  spinal  affections.     No  differential  diag- 


146 


ORTHOPEDIC  SURGERY. 


nosis  could  be  simpler  than  that  between  these  two  affections  In 
pronounced  lateral  curvature,  the  lateral  twist  and  the  rotation  are 
essentially  different  from  the  curve  of  Pott's  disease,  which  is  chiefly 
an  antero-posterior  curve.  In  the  former  rotation  is  an  unmistak- 
able symptom.  In  the  latter  it  is  absent  or  slight.  In  the  slighter 
cases  of  lateral  curvature  the  spine  is  flexible,  and  the  lateral  curve 

diminishes  or  disappears  on  recumbency; 
and  there  is  never  a  sharp  angular  projec- 
tion. In  Pott's  disease  the  spine  is  not 
flexible  but  stiff,  the  curve  is  not  lateral 
but  angular,  and  it  does  not  disappear  on 
recumbency. 

Methods  of  Recording  Lateral  Curvatiire. 
— Several  methods  of  recording  lateral  cur- 
vature have  been  recommended,  the  sim- 
plest being  the  measurement  of  the  tips  of 
the  scapulae  from  the  vertical  line  already 
mentioned,  and  a  measurement  of  the  dis- 
tance of  the  point  of  greatest  convexity 
from  the  median  line. 

Tracings   of  lead   outlines  of    the   sides 
of  the  trunk  are  of   value  if  accurate,  but 
Fig.  1 71. -Diagram  of  Lines  of  Dis-    they  are   not   readily  taken  with  accuracy. 

tortion  in  Lateral  Curvature. 

Casts  of  the  trunk  are  not  readily  taken 
with  accuracy  and  are  bulky  and  also  inaccurate. 

The  most  reliable  method  will  be  found  to  be  that  of  photo- 
graphing the  patient's  back.  The  back  should  be  marked  with 
crayons  on  the  spinous  processes  and  the  tips  of  the  scapulae,  and 
the  patient  should  stand  with  the  arms  crossed  in  front  of  the  body 
while  a  photograph  is  taken. 

Several  appliances  have  been  described  designed  to  record  cor- 
rect measurements,  of  which  Buhring's  and  Mikulicz's  and  Schult- 
hess's  should  be  mentioned.  Buhring's  apparatus  consists  of  a  glass 
plate  16  by  20  inches  fixed  in  a  frame.  The  patient  stands  in  front 
of  the  glass  plate,  a  tracing  on  paper  is  made  from  the  outline  of 
the  back  which  is  projected  upon  the  glass  plate.  Mikulicz's  scoli- 
osometer  consists  of  a  vertical  and  horizontal  arm,  the  latter  mov- 
ing upon  the  former.  The  vertical  portion  is  fixed  to  a  pelvic 
band,  and  to  the  end  of  the  vertical  portion  is  fixed  a  goniometer 
so  arranged  that  every  torsion  of  the  body  marks  a  deviation  on 
the  indicator  {Centralblatt  f.  Chir.,  1883,  p.  305).  Schulthess's  ap- 
pliance {Centralblatt  f.  OrtJiop.  Chir.,  1887,  No.  4)  is  said  to  be  effi- 
cient but  is  expensive.' 

'  A  much  cheaper  appliance  and  apparently  equally  efficacious  has  been  devised  by  Dr. 
C.  L.  Scudder,  of  Boston. 


LATERAL   CURVATURES  OF    THE  SPINE. 


147 


Proc;nosis. 

No  accurate  data  are  in  existence  wliich  enable  us  to  form  a 
definite  prognosis  in  this  peculiar  affection.  Two  errors  in  prog- 
nosis are  common.  Plrst,  that  the  disease  is  of  the  most  serious 
nature;  second,  that  it  is  a  trivial  affection  and  will  be  readily  out- 
grown by  the  patient.  The  fact  is,  that  in  the  larger  number  of 
these  cases  the  affection  is  a  self-limited   one,    occasioning   slight 


Fig.  172.  Fig.  173. 

Figs.  172  and  173.  — Schulthess   Appliance  for  Recording  Lateral  Cur\-ature. 

deformity,  which  persists  through  life,  causing  no  trouble  and 
recognized  only  by  the  dress-maker  or  by  some  near  relative. 

In  other  cases,  however,  the  disease  becomes  decided!}-  worse 
as  the  deformity  increases,  and  a  pitiable  distortion  follows,  causing 
a  great  deal  of  neuralgic  pain  and  a  pitiable  deformity. 

Sometimes  the  disease  may  remain  to  a  slight  extent  during 
girlhood  and  early  womanhood,  developing  an  increase  at  a  period 
past  middle  life.  Such  cases  are  rare,  and  are  dependent  upon 
a  loss  of  general  health.  It  is  impossible  to  state  in  what  in- 
stances an  increase  of  the  curve  will  take  place  and  when  they  can 
be  relied  upon  to  remain  stationary. 


148 


ORTHOPEDIC  SURGERY. 


It  may,  however,  be  said  that  where  the  physical  condition  dur- 
ing the  growing  period  remains  constantly  below  the  proper  stand- 
ard, and  where  the  patient's  growth  is  rapid,  an  increase  of  curve  is 
to  be  apprehended.  The  decrease  or  diminution  of  lateral  curva- 
ture from  simple  growth  without  treatment  has  never  been  seen. 

In  determining  the  prognosis  in  any  given  case  the  following 
facts  must  be  ascertained  and  borne  in  mind : 

First,  the  probable  rate  of  growth.  This  can  be  ascertained  by 
the  patient's  height,  the  hereditary  tendency  toward  height  as 
ascertained  by  the  height  of  the  parents  and  the  parents'  families. 
The  general  opinion  is  that  completion  of  growth  exerts  a  power- 
ful influence  in  arresting  progress  of  the  curvature.  In  a  girl  of 
health  at  the  age  of  twenty,  with  only  a  slight  degree  of  curvature, 
this  may  remain  without  increase  for  life,  or  for  a  while;  but 
there  remains  a  liability  to  increase,  and  Adams  notes  a  case  where 
a  patient,  with  a  slight  curvature  up  to  the  age  of  forty,  developed 
a  very  severe  curvature  at  sixty,  owing  to  failure  of  general  health. 

The  physician  should  bear  in  mind  certain  facts  as  to  the  rat.e 
of  growth  of  children.  Malling-Hansen,'  as  director  of  the  Royal 
Deaf  and  Dumb  Institution,  has  examined  130  children,  weighing 
them  at  different  times.  The  boys  were  weighed  at  6  a.m.  and  9  P.M. 
The  girls  were  weighed  once  a  day,  at  2  P.M.  He  found  that  a  child 
might  weigh  from  one  to  two  pounds  heavier  at  night  than  in  the 
morning,  and  be  more  than  one  pound  and  a  half  lighter  in  the 
morning  than  it  was  in  the  evening  before  exercise.  Bathing  did  not 
influence  the  weight.  There  was  always  an  increase  after  a  full  meal. 
He  found  that  there  were  three  periods  in  which  the  weight  varied  : 
first,  a  period  of  decrease  from  the  middle  of  May  in  each  year  to 
the  middle  of  July;  a  period  of  increase  of  great  importance  from 
the  middle  of  July  to  the  middle  of  November;  and  then  a  period  in 
which  the  child's  weight  increased  slightly,  but  often  remained  sta- 
tionary, and  might  even  diminish,  from  the  middle  of  November  to 
the  middle  of  May.  Temperature  had  an  effect  upon  increase  and 
decrease,  increase  of  temperature  being  accompanied  by  increase 
in  weight,  and  vice  versa.     Boys  consumed  one-fifth  more  than  girls. 

The  patient's  occupation  also  is  influential,  as  it  may  be  said  that 
if  a  patient  has  gained  full  height  and  development  in  figure,  any 
increase  in  growth  is  not  to  be  expected,  and  an  increase  in  curve 
is  not  probable  after  the  osseous  system  has  become  thoroughly 
formed,  though  such  an  increase  may  occur  if  there  is  a  failure  of 
health  and  strength. 

The  normal  height  and  weight  of  male  and  female  are  here  given 
for  the  sake  of  reference. 

^  Brit.  Med.  Journ.,  Sept.  20th,  1884. 


LATERAL    CUA'V  A  TUNICS   OL    77/ A'  SILXK. 


149 


Tahi.k 


)V  \\vm;\\:\  and  WKKiirr 
Atak. 


Ilr.MAN    P.OIA-. 


Age. 


At  birth,' 


I 

2 

3 
4 
5 
6 

7 
8 

9 

10 
12 

14 
16 

iS 
20 
25 
30 
40 


year, 
years, 


Height  in  Feet  and  Inches. 


I  ft. 


7  in, 
3    " 


(0.496  m. 

(o.  696  ' ' 

(0.797  " 

(0.860  " 

(0.932  " 

(0.990  " 

(1.046  " 

(1. 112  " 

(1.170  " 

(1.227  " 

(1.282  " 

(1-359  " 

(1.487  " 

(r.6io  " 

(r.700  " 

(1.711  " 

(1.722  " 

(1.722  " 

'(1-713  " 


Weight. 


7  lbs. 

(  3.20  kgm.) 

22  " 

(lO.CX)   ' 

26  " 

(12.00  ' 

29  " 

(13.21   ' 

33  " 

(15-07  ' 

3^'  " 

116.70  ' 

39  " 

(18.04  ' 

44  " 

(20.16  ' 

49  " 

(22.26  ' 

53  " 

(24.09  ' 

57  " 

(26.12  ' 

68  " 

(31.00  ' 

89  " 

(40.50  ' 

117  " 

(53-39  ' 

135  " 

(61.26  ' 

143  " 

(65.00  ' 

150  " 

(68.29  ' 

152  " 

(68.90  ' 

151  " 

(68. 91  ' 

Female. 


Age. 


Height  in  Feet  and  Inches. 


At  birth, 

1  year,    . 

2  years, 
3 
4 
5 
6 

7 


9 
10 
12 

14 
16 
18 
20 
25 
30 
40 


I  ft. 

6  in. 

(0.483  m.) 

2  " 

3  " 

(0.690  "  ) 

2  " 

6  " 

(0.780  "  ) 

2  " 

9  " 

(0.S50  "  ) 

3  " 

.  .  . 

(0.910  "  ) 

3  " 

2  " 

(0.974  "  ) 

3  " 

4  " 

(1.032  "  ) 

3  " 

7  " 

(i.og6  "  ) 

3  " 

9  " 

(1-139  "  ) 

3  " 

II  " 

(1.200  "  ) 

4  " 

I  " 

(1-243  "  ) 

4  " 

4  " 

(1.327  ") 

4  " 

9  " 

(1-447  "  ) 

4  " 

II  " 

(1.500  "  ) 

5  " 

I  " 

(1-562  "  ) 

5  " 

2  " 

(1-570  "  ) 

5  " 

2  " 

(1-577  "  ) 

5  " 

2  " 

vi-579  "  ) 

5  " 

I  " 

(1-555  ") 

6  lbs 

(  2.91  kg 

m.) 

20  " 

(  9-30  ' 

25  " 

(11.40  ' 

27  " 

(12.45  ' 

31  " 

(14.1S  ' 

34  " 

37  " 

(15.50  ' 
(16.74  ' 

40  " 

(1S.45  ' 

43  " 

(19.82  ' 

50  " 

(22.44  ' 

53  " 
67  " 
84  " 
98  " 

(24.24  ' 

(30.54  ' 
(3S.10  ' 

(44-44  ' 

117  " 

120  " 

121  '• 

(53- 10  ' 
(54.46  ' 
(55-oS  ' 

121  " 
129  " 

(55-14  ' 
(58.45  ' 

The  conclusions  of  Pravaz  are  well  expressed,  who  considers 
that  "  the  patient's  general  condition  is  of  great  importance  in  the 
prognosis  of  lateral  curvature.  Chlorosis  and  imperfect  nutrition 
are  unfavorable  to  the  re-establishment  of  the  figure.  In  general, 
recovery  of  the  figure  is  more  to  be  expected  in  younger  than  in 
older  patients,  but  the  writer  wishes  to  warn  against  the  prevalent 
idea  that  patients  will  grow  out  of  a  curve  of  the  spine.  The  prog- 
nosis in  curvature  following"  phthisis  is  unfavorable,  and  distortions 


ISO 


ORTHOPEDIC  SURGERY, 


due  to  disturbances  of  muscular  action  are  often  very  difficult  to 
treat,  and  rickety  distortions  are  more  unfavorable  for  treatment 
than  those  due  to  a  loss  of  flexibility  of  the  spine  in  children  at  the 
time  of  the  second  dentition  or  puberty.  Curvatures  submitted  to 
treatment  at  an  early  stage,  even  when  quite  pronounced,  may  be- 
come corrected  provided  the  patient's  general  condition  is  good, 
the  prognosis  depending  in  a  large  measure  upon  the  amount  of 
rotation  of  the  vertebrae  present,  rather  than  on  the  amount  of  the 
curve.  Curvatures  in  the  lumbar  region  are  less  favorable  than 
those  in  the  dorsal  region,  and  curvatures  with  a  long  radius  are 
more  readily  straightened  than  those  with  a  short." 

The  lateral  curvature  seen  in  early  Pott's  disease  is  easily  cor- 
rected by  the  proper  treatment  for  caries  of  the  spine.  The  de- 
formity which  comes  on  in  the  later  stages  and  is  dependent  on  osse- 
ous change  is  irremediable. 

Preventive  Measures. 


As  faulty  attitudes  exert  an  important  influence  in  causing  lat- 
eral curvatures,  the  avoidance  of  these  is  of  importance  in  prevent- 
ing curves.  The  attitude  assumed  in  sitting  is  necessarily  of  great 
importance.  The  accompanying  pictures  depict  the  attitude  usu- 
ally taken  by  children  in  writing,  as  well  as  the  desirable  attitude. 


Fig.  174. — Faulty  Attitude. 


Fig.  175. — Corrected  Attitude. 


Schenk  ("  Zur  .Etiology  der  Scoliosis,"  Berlin,  1885)  has  studied 
the  attitude  in  writing  assumed  by  200  school  children. 

In  160  the  trunk  was  found  inclined  with  a  convexity  of  a  lower 
dorsal  curve  in  160  cases. 

In  34  the  trunk  inclined  toward  the  right,  but  the  body  twisted 
toward  the  left. 

In  only  6  was  there  no  twist  of  the  body. 

In  only  38  was  the  transverse  axis  of  the  body  parallel  with  the 


LATERAL   CURVATUKl-S   ()/■-    Till-:  SriNE.  151 

desk,  and  in  the  others  the  pelvis  was  twisted  obhquely  tfj  the 
right. 

The  writers  have  taken  the  opixirtiinity  to  examine  the  attitude  as- 
sumed in  writini,^  by  67  healthy  adult  males,  while  writinc;  in  a  three- 
hour  written  examination.  At  the  end  of  two  hours  the  attitudes 
were  observed.  In  all  the  paper  was  inchned  slightly,  so  that  the 
written  line  formed  an  angle  with  the  cross  axis  of  the  thorax.  This 
angle  varied  from  ten  degrees  to  a  right  angle.  The  inclination  of 
the  paper  was  always  such  that  the  right  upper  corner  was  in  front 
of  the  left.  In  a  large  majority  of  the  writers  the  left  side  of  the 
hip  was  in  front  of  the  right,  the  left  shoulder  in  front  of  the  right, 
but  th«  left  ear  was  usually  slightly  lower  than  the  right  and  some- 
what behind  it.  In  all  cases,  therefore,  there  was  a  slight  rotation 
of  the  spinal  column.  The  trunk  in  three-fourths  of  the  writers 
was  inclined  to  the  left,  in  about  one-quarter  to  the  right,  and  in 
the  remainder  it  was  held  erect. 

It  may  be  fairly  assumed  that,  if  a  twist  of  the  spinal  column  is 
invariable  in  writing  in  strong  men,  faulty  attitudes  will  be  equally 
common  in  weakly  children. 

The  proper  attitude  during  writing  is  with  the  transverse  axis  of 
the  trunk  parallel  with  the  edge  of  the  waiting  table.  The  fore- 
arms should  rest  at  least  two-thirds  of  their  length  upon  the  table. 
The  trunk  should  be  held  erect,  the  legs  should  be  straight  be- 
fore the  trunk,  and  the  feet  should  rest  upon  a  sloping  cricket 
which  rests  and  steadies  the  legs. 

Scats, — Chairs  used  by  children  frequently  do  not  properly  sup- 
port the  back  muscles,  which  may  be  unduly  stretched  and  thereby 
weakened.  Children  often  assume  faulty  attitudes  simply  for  the 
reason  that  proper  support  is  not  furnished  the  lower  part  of  the 
back. 

The. accompanying  pictures  show  the  profile  of  a  proper  support 
for  a  school  chair  designed  by  Liebreich,  and  also  a  reclining  chair. 

A  fruitful  source  of  faulty  attitudes  in  sitting  is  furnished  ^by 
chairs,  which,  not  fitting  the  child  or  supporting  the  back  properly, 
induce  the  patient  to  sit  sideways,  the  trunk  being  supported  on 
one  tuberosity  of  the  ischium  and  on  one  elbow.  The  seat  of  the 
chair  in  which  the  child  is  to  sit  for  any  length  of  time  should 
not  be  deeper  than  the  length  of  the  thighs  or  higher  than  the 
length  of  the  legs;  its  back  should  not  be  above  the  shoulders  and 
should  be  arched  so  as  to  fit  in  the  hollow  of  the  back;  or  if  this  is 
not  practicable,  hard  cushions  or  false  chair  backs  made  of  leather 
stiffened  with  steel  should  be  placed  in  the  back  of  the  chair  so 
fitted  as  to  act  as  a  proper  support. 

For  children  with  weak  backs  it  is  advisable  that  the  lower  part 


152 


ORTHOPEDIC  SURGERY. 


of  the  back  should  be  well  supported.  If  this  is  not  done,  the  large 
muscles  of  the  back  will  be  unduly  strained,  as  they  are  inserted 
into  the  broad  fascia,  which  is  attached  to  the  sacrum  and  iliac 
bones,  and  faulty  attitudes  will  be  instinctively  assumed  by  the 
patient. 

The  back  of  the  chair  should  slope  backward  slightly,  forming  an 
angle  of  ioo°  to  iio°  with  the  seat.  The  back  of  the  chair  should 
be  arched  with  the  convexity  forward,  the  greatest  convexity  cor- 
responding to  the  physiological  curve  in  the  hollow  of  the  back. 
The  back  of  the  chair  should  be  constructed  so  that  it  will  serve 


Fig.  176. — Diagram  showing  Imperfect  Support  of  Back 
in  Badly  Fitting  Chair. 


Fig.  178.— Liebreich's  Chair  and  Desk  for 
School  Children  with  Weak  Back. 


as  a  comfortable  support  to  the  whole  spine  when  the  child  leans 
backward.  The  backs  of  most  chairs  simply  touch  the  shoulders 
of  children  in  the  upper  dorsal  region.  Liebreich's  school  chair  is 
designed  to  meet  this  end.  Staffel  has  advised  the  use  of  a  lumbar 
back  rest,  which  can  be  secured  to  a  chair  at  a  proper  height;  it 
should  be  narrow  enough  to  fit  into  the  lumbar  region. 
The  following  measurements  are  adapted  from  Staffel:' 


6-9  years. 

Height  from  seat  to  floor, •     33  c.m. 

Height  from  seat  to  middle  of  lumbar  pro- 
jection of  chair, 21    " 

From  edge  of  seat  to  vertical  line  drawn 

•  from  lumbar  projection  to  seat,   .     .     26   " 


II. 

g-T2  years. 

37  cm. 
23   " 
30   " 


III. 

12-15  years. 

41  cm. 


IV. 
Adult. 

47  cm. 


27 


34 


38 


Staffel,  Centralblatt  f.  orthop.  Chin,  May  ist,  1885. 


LATERAL    CURVATUKES   OR    THE  SRLXE. 


153 


Fig.  179. 


-School  Bench  and  Seat  with  Support  for  Hollow  of 
Back. 


These  pictures  illustrate  a  f(;rin  of  school  chair  whicli  will  be 
found  to  support  the  hollow  of  the  back.  The  writing  table  should 
be  at  a  height  proportionate  to  the  height  of  the  person  sitting. 
The  distance  from  the 
top  of  the  seat  to  the 
top  of  the  table  should 
b e  one-eighth  of  the 
height  of  a  girl,  and  one- 
seventh  of  that  of  a  boy. 
The  height  can  also  be 
determined  in  the  fol- 
lowing ready  way:  The 
distance  from  the  olecra- 
non of  the  bent  arm  to 
the  seat  with  two  inches 
added  should  be  the  dis- 
tance from  the  seat  to 
the  top  of  the  desk.  The 
edge  of  the  table  should 
be  just  over  the  edge  of  the  chair.  The  inclination  of  the  top  of 
the  desk  should  be  a  slope  of  two  inches  in  a  breadth  of  twelve. 

Attitude  During  Sleep. — The  attitude  during  sleep  is  of  import- 
ance. To  determine  the  attitudes  usually  assumed  by  children, 
the  accompanying  observations  were  made  by  Dr.  E.  G.  Brackett, 
who  was  allowed,  by  the  courtesy  of  the  Superintendent,  Dr.  Heath, 
to  examine  the  decubitus  of  the  children  in  the  Marcella  Street 
Home,  Boston. 

320  healthy  children  were  observed  with  reference  to  the  decubitus 

while  asleep.  Of  this  number 
156  were  boys,  164  girls.  The 
majority  w^ere  between  6  and 
14  years  of  age,  and  all  be- 
tween 4  and  16.  It  was  noted 
whether  the  child  was  lying  on 
the  back,  side,  or  stomach.  In 
many  instances  the  decubitus 
was  so  nearly  dorsal  that  it 
was  a  question  under  what 
head  it  should  be  placed,  but 
none  were  considered  as  h'ing 
on  the  side  unless  the  position  was  such  that  the  pressure  was 
borne  on  one  side  of  the  thorax.  In  about  three-fourths  of  the 
number  seen,  the  position  was  easy,  the  body  straight,  and  head 
on  the  pillow,   exposed.     In  several  the  head  was  so  thoroughly 


Fig.  iSo. — School  Bench  and  Seat  with  Support  for 
Hollow  of  Back. 


154 


OR  THOPEDIC  S  URGER  Y. 


wrapped  in  the  blanket,  that  it  could  not  be  removed  without 
almost  shaking  the  child  out.  Among  those  not  lying  on  the 
back,  the  favorite  position  was  on  the  side,  with  the  knees  drawn 
up  nearly  to  the  abdomen,  and  the  head  bent  forward  toward  the 
thorax.  Among  the  girls,  this  position  was  more  common  and 
more  extreme.  One  position  was  seen  closely  resembling  that  of 
the  foetus  in  utero.  The  child,  a  boy  of  five,  was  sitting  on  the 
right  buttock,  with  the  body  thrown  forward  and  to  the  right  side, 
with  the  knees  in  apposition  to  the  thorax,  and  the  feet  crossed. 
The  head  had  fallen  forward,  the  face  resting  on  the  knees,  one 
arm  lay  across  the  chest,  the  right  seemed  to  be  under  the  side. 
In  this  position  the  child  was  soundly  asleep,  and  required  a  shak- 
ing to  be  roused. 

The  figures  show  the  positions  to  be  about  equally  distributed 
among  the  three — back,  right  and  left  side,  except  with  the  boys 
from  lO  to  14,  among  whom  there  were  a  majority  on  the  back. 
In  the  others  the  age  did  not  seem  to  influence  the  tendency. 


Boys, 4-7 

"        10-15 

Girls, 4-8 

8-10 

.     .  8-12 

9-14 


Back. 
21 

41 
62 

13 
12 

7 
51 


R. 
24 
20 

44 

14 
17 
20 


59 


L. 
15 


39 

15 
12 
16 


49 


Stomach. 

4 
7 

II 

2 
I 


5 


Dr,  Hare,  of  Boston,  examined  the  decubitus  of  the  healthy  in- 
mates in  one  of  the  penal  institutions  of  Boston,  recording  the 
positions  observed  after  10  P.M,,  that  is  from  one-to  two  hours  after 
the  time  the  inmates  went  to  bed. 

The  results  were  as  follows  : 


Lay  on 
Back. 

Lay  on  the 
Right    Side. 

Lav  on  the 
Leftside. 

Stomach. 

Total. 

Men, 

Women 

Boys, 

536 
136 

68 

384 

74 
73 

321 
56 
15 

24 
0 

8 

1292 
266 

164 

Totals,     .     .     . 

767 

531 

392 

32 

1722 

The  decubitus  of  the  boys  in  this  table  is  to  be  noticed. 
The  frequency  of  the  decubitus  on  the  right  side  is  quite  marked, 
and  is  explained  by  the  fact  that  the  boys  were  all  required  to  lie 
upon  the  right  side  when  they  went  to  sleep  to  prevent  conversa- 


LATERAL    CURVATURES   OF    TJIE  SJ'FNE 


155 


tion,  two  hours  later  some  had  turned  on  tlie  face,  some   upon  the 
left  side. 

It  will  be  seen  that  the  most  common  attitude  in  sleep  is  upon 
the  side,  but  that  decubitus  upon  the  back  is  more  common  than 
on  either  single  side.  The  right  side  is  more  commonly  lain  on 
than  the  left,  but  the  difTerence  is  slight;  young  children  and  men 
not  infrequently  lie  upon  the  belly,  but  the  attitude  is  not  assumed 
by  women  or  growing  girls. 

The  fact  that  a  right-sided  decubitus  is  to  be  avoided  in  a  right 
dorsal    convex    curve    makes 
these  facts  of  value. 

Faulty  attitudes  are  fre- 
quently assumed  in  walking 
and  in  standing,  especially  by 
young  children.  The  habit  of 
standing  upon  one  leg  is  usu- 
ally a  habit,  but  in  some  cases 
it  may  be  due  to  a  muscular 
weakness  of  one  limb  or  of  a 
knee  or  ankle.  The  habit  is 
to  be  corrected,  if  possible,  by 
drill  or  by  muscular  exercise. 

In  ordinary  cases  the  pre- 
cautions at  night  which  should 
be  observed  are  that  the  pa- 
tient should  not  be  allowed  to 
sleep  with  many  pillows,  and 
the  bed  should  be  a  firm  one. 
The  child  should  not  be  al- 
lowed to  assume  a  twisted  po- 
sition, but  should  lie  upon  the 
back  or  the  side  of  the  great- 
est  concavity.       In  threatening     Fig.  iSi.— Faulty  Attitude  of  Child,  Laterally  Curving 

Spine. 

cases  measures  are  necessary 

to  preserve  a  proper   position.     This  can    be    done  by  means  of 

bed  frames,  described  under  caries  of  the  spine. 

Much  has  been  said  about  the  injurious  effects  of  corsets,  and 
there  is  no  doubt  that  the  muscles  of  the  trunk  are  weakened  by 
the  wearing  of  corsets  (Hutchinson,  N.  Y.  Med.  Record,  April  27th, 
'89,  p.  464),  The  custom  is  at  present  so  prevalent  that  it  is  difii- 
cult  to  prevent  patient^  from  wearing  corsets  unless  under  fear  of 
immediate  injury.  The  injury  from  corsets  may  be  made  less  by 
seeing  that  the  lacings  are  elastic  and  the  waist  boneless  or  fur- 
nished with  slis^ht  steels. 


156  ORTHOPEDIC  SURGERY. 

Treatment  of  Lateral  Curvature. 

Several  difficulties  are  to  be  met  with  in  treating  lateral  curva- 
ture. As  the  affection  is  active  during  the  period  of  growth,  treat- 
ment, to  be  efficient,  must  be  carried  on  for  a  long  time  and  this  is 
tedious  to  the  surgeon  and  irksome  to  the  patient.  Furthermore, 
as  the  disease  is  one  that  does  not  threaten  life  and  is  slow  and 
uncertain  in  its  outcome,  it  is  sometimes  difficult  to  enforce  the 
proper  treatment  for  the  requisite  length  of  time.  Again,  the  dis- 
tortion and  danger  vary  at  different  periods  of  the  trouble,  and 
consequently  methods  which  are  necessary  at  certain  stages  of  the 
affection  are  not  needed  later  on. 

As  has  been  said  above,  lateral  curvature  is  a  curve  and  torsion 
of  the  spinal  column,  due  to  the  superincumbent  weight  falling 
irregularly  upon  a  weakened  spinal  column  which  is  constantly 
held  out  of  line.  There  are,  therefore,  three  ways  in  which  an  in- 
crease of  distortion  can  be  prevented : 

1.  By  removing  the  superincumbent  weight. 

2.  By  strengthening  the  weakened  spinal  column. 

3.  By  preventing  the  spinal  column  from  being  held  constantly 
out  of  line. 

I.  Removal  of  Superincumbent  Weight. — Recumbency  is  the  only 
practical  way  in  which  removal  of  the  superincumbent  weight  can 
be  applied  for  any  length  of  time,  as  suspension  must  be  a  tempo- 
rary measure  and  recumbency  constituted  the  chief  method  of 
treatment  of  the  older  orthopedic  surgeons. 

At  present,  however,  we  cannot  consider  that  this  is  a  method  of 
treatment  which  commends  itself  for  continuous  use  for  any  length 
of  time  in  the  treatment  of  lateral  curvature,  for,  if  prolonged  for 
any  great  length  of  time,  it  necessarily  injures  the  patient's  general 
condition,  weakens  the  muscles,  and  does  not  promote  the  forma- 
tion of  solid  bone  in  the  spinal  column,  so  that  the  weight  can  be 
borne  without  the  yielding  of  the  column.  In  cases  of  very  rapid 
growth,  where  there  is  much  fatigue,  as  in  neurasthenic  cases,  re- 
cumbency, either  on  the  back  or  in  the  prone  position,  may  be 
advisable  if  carried  out  to  the  extent  of  rest  for  several  hours  of 
the  day. 

The  use  of  a  distracting  force,  which  is  described  in  the  works  of 
the  older  orthopedic  surgeons  with  the  intention  of  obliterating 
the  curve  by  a  direct  pull,  is  inefficient,  as  the  amount  of  force  that 
can  be  applied  for  any  length  of  time  is  not  sufficient  to  effect  as 
much  as  the  simple  position  of  recumbency.  This  has  already 
been  demonstrated  in  spondylitic  curves  and  is  equally  true  of  the 
fixed  curves  of  scoliosis. 


LATERAL    CURVATURES   UE    THE  SPINE. 


157 


The  ternporary  use  of  suspension  by  the  head  can  be  added  as  a 
means  of  daily  exercise,  and  can  be  i^erformed  by  means  of  the 
head  sling  attached  to  a  sliding  bar  in  the  ceilinc,^  or  to  a  wheel 
carriage,  as  indicated  in  the  accompanying  diagram.  The  employ- 
ment of  this  method  for  the  sole  and  continuous  treatment  of  lat- 
eral curvature  is  of  course 
impossible,  as  the  disease 
ordinarily  runs  its  course 
through  several  years,  but  in 
extreme  cases  such  methods 
maybe  applied  temporarily. 
2.  To  Strengthen  the  Weak- 
ened Spinal  Cohinin. — Any 
attempts  to  strengthen  the 
bony  structure  in  the  pres- 
ent state  of  our  therapeu- 
tic knowledge  must  be  lim- 


FiG.  182. — Position  for 
Application  of  Plaster 
Jacket. 


Fig.  183. — Pulley  for  Attachment 
of  Self-sustaining  Appliance. 


Fig.  184. — Means  of  Fixation  of  Pelvis 
in  Application  of  Plaster  Jacket. 


ited  to  the  administration  of  tonics,  and  an  improvement  of  the 
digestion,  assimilation,  and  encouraging  exercise  and  fresh  air  as 
far  as  it  is  practicable. 

The  spinal  column,  however,  can  be  strengthened  in  its  practical 
power  of  resistance  by  increasing  the  strength  of  the  muscles 
which  hold  it  erect,  as  will  be  seen  under  the  description  of  gym- 
nastics. 


158  ORTHOPEDIC  SURGERY. 

3.  Prevention  of  Faulty  Positions  of  the  Spinal  Column. — There 
are  three  methods  by  which  this  can  be  accompHshed : 

The  postural, 

The  gymnastic,  and 

The  mechanical. 

Postnral. — The  postural  treatment  is  that  method  where  correc- 
tion is  sought  by  instruction  in  proper  attitude.  As  a  raw  recruit 
is  taught  the  position  and  carriage  of  the  soldier,  so  children  are  to 
be  drilled  into  standing  and  walking  erect.  This  method  is  suited 
for  the  simplest  cases.  To  be  thoroughly  carried  out,  it  requires 
that  the  patient  should  daily  be  exercised  in  walking,  standing,  and 
sitting  properly  for  a  specified  time  under  the  direction  of  some 
competent  person.  When  resting  during  the  hour  of  drill  the 
patient  should  remain  recumbent.  After  the  drill  is  over,  such  pre- 
caution should  be  taken  as  will  prevent  the  persistence  for  any 
length  of  time  of  a  faulty  attitude.  This  should  not  be  done  (out 
of  the  drill  time)  by  constant  correction,  but  by  the  proper  arrange- 
ment of  the  play  hours,  and  a  supervision  of  the  chairs  when  read- 
ing and  studying.  Walking,  running,  and  active  games  should  be 
encouraged,  while  reading,  except  in  proper  position,  should  be  dis- 
couraged. A  certain  amount  of  time  should  be  given  to  proper 
rest  of  the  back. 

The  usual  bad  habits  of  position  are  as  follows:  standing  on  one 
leg,  sitting  at  too  low  a  table,  sitting  in  a  twisted  position,  and 
sleeping  always  on  one  side  with  too  high  a  pillow  for  the  head. 

In  most  early  cases  the  faulty  attitudes  are  clearly  the  result  of 
muscular  weakness.  The  growth  in  size  has  not  been  accompanied 
by  a  corresponding  development  of  muscle.  This  condition  is  fre- 
quently met  in  rapidly  growing  children,  and  is  one  of  the  most 
common  causes  of  lateral  curvature.  Here  proper  gymnastics  are 
indicated,  but  they  should  be  prescribed  and  carried  out  with  much 
care.  In  cases  of  gravity,  the  children  are  unable  to  bear  much 
exercise  without  fatigue.  Those  exercises,  therefore,  chiefly  needed 
in  correcting  the  deformity,  should  be  the  only  ones  prescribed. 
The  usual  class-work  of  the  gymnasia  is  to  be  avoided,  as  such 
cases  require  the  individual  attention  of  a  competent  person,  who 
will  see  that  no  faulty  position  is  taken  during  the  exercises. 

Mr.  Bernard  Roth,  of  London,  has  devoted  much  time  and  at- 
tention to  the  development  of  proper  simple  gymnastics,  combined 
with  postural  treatment,  the  efificiency  of  which  he  has  demon- 
strated by  a  series  of  successful  cases.  He  has  pointed  out  that  in 
each  individual  a  certain  attitude  can  be  voluntarily  assumed  by 
the  patient,  which  is  the  nearest  approach  to  the  normal.  This 
attitude  varies  to  a  degree  in  each  case,  and  must  be  ascertained 


LATERAL    CURVATURES   OE    TIIIC  S/>/j\E.  159 

by  experiment.  The  first  step  I'n  treatment  should  be  to  determine 
this  position,  which  he  calls  the  "  k-ey-note  "  position.  All  exer- 
cises should  be  made  in  such  a  way  as  to  develop  the  muscles 
involved  in  this  attitude,  or  while  the  attitude  is  maintained.  The 
following  are  the  exercises  which  he  prescribes,  varying  in  a  mea- 
sure in  individual  cases  : 

1.  Lying  on  the  back,  arms  by  the  side,  hands  supinated,  very 
slow  deep  inspirations  by  the  nose,  expiration  by  the  mouth. 

2.  The  same,  with  arms  extended  above  the  head. 

3.  Position  the  same  as  No.  i,  head  rotation,  lateral  flexion  of 
head. 

4.  Position  the  same,  simultaneous  circumduction  of  both  shoul- 
der joints  from  before  backward,  elbows  and  wrists  extended. 

5.  Position  the  same,  one  hip  circumducted  both  ways  (knees 
extended). 

6.  Lying  on  back,  simultaneous  extension  of  both  arms  upward, 
outward,  downward,  from  a  position  of  the  elbows  flexed  and  close 
to  the  trunk. 

7.  Lying  prone,  one  hip  circumducted  both  ways,  knee  kept  ex- 
tended. 

8.  Sitting  on  couch,  with  the  back  at  an  angle  of  45°,  ankle  cir- 
cumducted in,  up,  and  out,  while  the  toes  are  inward  the  whole 
time. 

9.  Lying  on  back  with  arms  extended  upward  by  the  sides  of 
the  head,  flexion  of  both  arms  (surgeon  resisting).  (The  patient's 
knees,  flexed  over  the  end  of  the  table,  fix  the  trunk.) 

10.  Patient  astride  a  narrow  table,  with  the  arms  down  and 
hands  supinated,  trunk  flexion  at  lumbar  vertebrse  (patient  resist- 
ing), followed  by  trunk  extension  (surgeon  resisting). 

11.  Patient,  with  arms  extended  upward,  leans  against  a  vertical 
post  with  pegs  on  each  side ;  these  he  grasps.  The  surgeon  gently 
pulls  the  patient's  pelvis  forward  by  his  hands  on  the  sacrum 
(patient  resisting),  also  pelvis  rotation  on  its  axis  to  right  and  left 
alternately  (surgeon  resisting),  with  the  hands  on  each  side  of  the 
pelvis. 

12.  Lying  on  back  with  head  and  neck  projecting  beyond  the 
end  of  table,  the  head  is  gently  flexed  by  the  surgeon's  hand  on 
occiput  (patient  resisting).' 

It  is  not  a  difificult  matter  to  devise  simple  and  practicable  exer- 
cises to  develop  these  back  muscles.  The  strength  of  a  patient's 
back  muscles  can  be  determined  in  a  ready  way  by  attaching  a 
cord  to  the  front  of  a  cap  tied  to  the  head,  and  fastening  this  cord 

^  British    Medical  Journal,  May    13th,   1882;  and  also  Walsham,  St.  Bartholomew's 
Hospital  Reports,  vol.  .xx. ,  195. 


l6o  ORTHOPEDIC  SURGERY. 

to  a  spring  balance.  The  patient,  seated  at  the  proper  distance 
from  the  spring  balance,  held  firmly  by  an  assistant,  is  directed  to 
bend  backward  keeping  the  back  straight  so  far  as  is  possible,  and 
the  amount  of  the  pull  is  inidcated  upon  the  dial/  A  record  of 
this  registers  any  increase  in  the  strength  of  the  patient,  and  as  a 
clinical  fact  it  will  be  found  that  an  improvement  in  carriage  will 
correspond  to  an  improvement  in  the  indicated  strength. 

The  management  of  cases  of  this  sort  may  be  described  in  a 
general  way  as  follows : 

After  a  careful  inspection  of  the  deformity,  and  a  diagnosis  as  to 
the  flexibility  of  the  curves,  and  examination  of  the  faulty  attitudes, 
the  child's  height  and  weight  should  be  taken  and  a  comparison 
made  with  the  standards  established  by  Bowditch's  tables,^  or  the 
tables  of  measure  for  weight  and  height  mentioned  under  the  head 
of  prognosis,  in  order  to  determine  whether  any  excess  of  growth 
in  height  or  deficiency  in  weight  exists.  It  should  be  considered 
that  if  a  child  has  grown  with  unusual  rapidity,  or  if  the  height 
had  increased  without  a  proportionate  increase  of  weight,  greater 
care  should  be  exercised  in  the  management  of  the  case.  The 
patient  should  then  be  directed  and  taught  to  sit  and  stand  and 
walk  in  as  nearly  a  normal  position  as  possible,  and  be  drilled  to 
assume  this  position.  It  should  be  the  object  of  the  attendant  to 
see  that  all  exercises  taken  during  the  exercise  hour  should  be 
done  without  an  assumption  of  a  faulty  attitude.  The  exercises 
assigned  should  vary  in  each  caes.  In  addition  to  those  already 
mentioned  the  following  will  be  found  of  use: 

1.  The  patient  sits  facing  the  assistant  who  holds  a  strap  passing 
about  the  patient's  occiput  (prevented  from  slipping  by  a  cross 
strap  around  the  head  and  chin).  The  patient  bends  forward  and 
back,  keeping  the  spine  straight.  The  backward  movement  is  re- 
sisted by  the  assistant. 

2.  Same  as  above,  except  that  the  straps  cross  the  shoulders. 
These  exercises  may  be  carried  on  with  a  weight  and  pulley,  or 

rubber  exercising  tubes  instead  of  the  resistance  of  the  assistant, 
but  the  amount  of  force  is  less  readily  regulated.  The  assistant 
should  correct  any  arching  of  the  back. 

3.  The  patient  stands  facing  a  wall  at  arm's  length  from  it; 
places  the  left  hand  upon  the  wall  at  the  height  of  the  chin,  the 
hand  being  in  a  direction  across  the  body.  The  patient,' supported 
by  the  arm,  slowly  brings  the  face  toward  the  arm,  bending  at  the 

'  By  fastening  a  spring  balance  to  the  wall,  and  an  arrangement  with  pulleys  and  cord 
connected  to  straps  fastened  to  the  patient,  the  actual  amount  of  force  in  different  move- 
ments can  be  estimated. 

^  Reports  of  the  Mass.  State  Board  of  Health. 


LATKEAL    CURVATUI^I'lS   Ol'     77//':  S/'/N/L  i6l 

ankles,  kccpiriL;  the  wlic^le  !)()(ly  in  line;  the  face  slioiihl  be  turned 
so  that  the  left  ear  touches  the  hand,  and  tlie  standin^^r  pfjsition 
slowly  resumed,  the  body  bein<^  still  kept  from  bendint^  at  the  hijxs. 

4.  The  patient  stands  with  the  heels,  back  and  occiput  against  a 
projecting  corner  (of  furniture  or  doorway),  and  places  the  elbow 
(the  arm  being  flexed)  as  far  back  as  possible. 

5.  The  patient,  seated  on  a  stool  or  chair,  should  i)]ace  the  feet 
behind,  and  on  the  inner  side  of,  the  front  legs  of  the  chair,  and 
slowly  bend  sideways;  the  assistant,  resisting  on  the  head,  deter- 
mines the  strain  on  the  muscles  of  either  side. 

For  children  accustomed  to  stand  upon  one  leg,  the  best  exer- 
cise is  to  drill  them  to  stand  upon  the  other  for  a  specified  number 
of  minutes,  and  standing  on  one  leg  to  lower  and  raise  the  body, 
bending  at  the  knee. 

Exercises  carrying  out  the  principles  advocated  by  Roth,  have 
been  recommended  by  Dr.  R.  H.  Sayre  {N.  V.  Med.  Journal,  Nov. 
17th,  1888,  p.  538),  who  describes  them  as  follows: 

In  beginning  the  exercises  a  mat  or  thick  shawl  is  laid  on  the 
floor  and  the  patient  lies  prone,  the  arms  at  right  angles  to  the 
trunk,  palms  down,  face  turned  to  the  convex  side,  and  the  back  as 
straight  as  possible.  The  patient  supinates  the  hands,  throws  the 
scapulse  well  back,  raises  the  hands  from  the  floor,  and  lifts  the 
trunk,  while  the  surgeon  holds  the  feet  doAvn.  This  is  repeated 
three  times;  later  on  it  can  be  done  oftener.  The  breath  should 
not  be  held  during  any  of  these  exercises,  but  the  patient  should 
breathe  naturally.  If  necessary  to  secure  this,  make  them  count 
out  loud  while  exercising. 

With  the  hands  behind  the  head,  the  patient  raises  the  elbows 
from  the  floor,  and  raises  the  trunk  as  before,  the  feet  being  held 
by  the  surgeon. 

With  the  hands  behind  the  head  and  the  elbows  raised,  the  body 
is  swayed  toward  the  convex  side,  the  patient  trying  to  "  pucker 
in  "  the  bulging  ribs  and  not  to  bend  in  the  lumbar  concavit}'.  The 
feet  are  fixed  as  before. 

With  the  arm  on  the  side  of  the  convexity  under  the  body,  the 
other  arm  over  the  head,  the  heels  fixed,  the  patient  raises  the 
trunk  from  the  floor. 

Sometimes  the  arm  on  the  side  of  the  concavity  is  put  on  the 
opposite  buttock  while  the  patient  raises  the  trunk.  Sometimes 
the  arm  on  the  convex  side  is  put  on  the  buttock,  and  in  cases  of 
marked  lordosis,  with  great  stooping  of  the  shoulders,  both  hands 
are  put  on  the  buttocks  while  the  patient  raises  the  trunk. 

The  patient  now  lies  on  the  back,  arms  at  the  sides,  palms  up, 
and  lifts  first  one  foot  in  the  air,  while  the  surgeon  makes  resist- 
II 


1 62  ORTHOPEDIC  SURGERY. 

ance  graduated  to  the  patient's  power;  repeated,  say,  five  times. 
The  same  is  done  with  the  other  foot,  and  then  with  both.  The 
feet  are  next  separated  and  then  brought  together  once  more  while 
the  surgeon  resists.  Each  leg  then  describes  a  circle,  first  from 
within  out,  then  from  without  in. 

If  there  is  special  weakness  at  the  ankles,  with  a  tendency  to  flat- 
foot,  the  patient  flexes  the  foot  and  extends  it  against  resistance, 
and  turns  the  sole  of  the  foot  toward  its  neighbor,  the  surgeon  re- 
sisting, and  it  is  then  forcibly  everted  again  by  the  surgeon,  the 
patient  resisting. 

The  patient  now  lifts  the  arms  from  the  sides,  passing  perpen- 
dicularly to  the  floor  till  they  are  stretched  as  far  beyond  the  head 
as  possible  and  then  going  at  right  angles  to  the  trunk  and  parallel 
with  the  floor,  returns  them  to  sides  palms  up.  While  the  heels 
are  held,  the  patient  rises  to  a  sitting  position,  hands  at  the  sides ; 
then  she  rises  from  the  floor  with  the  hands  behind  the  head  and 
the  elbows  at  right  angles  to  the  trunk. 

The  patient  now  stands  with  the  heels  together;  toes  turned 
slightly  out,  hands  behind  the  head,  elbows  at  right  angles  to  the 
trunk;  then  rises  on  tip-toe,  bends  the  knees  and  hips,  keeping  the 
back  as  straight  and  erect  as  possible,  and  rises  up  once  more. 
With  the  arm  on  the  concave  side  high  above  the  head,  the  arm  on 
the  convex  side  at  right  angles  to  the  body,  she  rises  on  tip-toe,, 
bends  the  hips,  knees,  and  ankles  so  as  to  squat,  then  rises  and 
stands.  All  this  time  care  must  be  taken  to  push  the  body  as 
straight  as  possible,  and  gradually  educate  the  patient  to  hold  it 
so,  without  wiggling  during  these  movements. 

Let  the  patient  practise  walking  in  these  positions,  both  on  the 
flat-foot  and  tip-toe,  and  also  step  high  as  if  walking  up  stairs. 
With  the  palm  of  the  patient's, hand  on  the  convex  side  against  the 
ribs,  pushing  them  in,  the  hand  on  the  concave  side,  she  pushes  a 
slight  weight  up  in  the  air  while  the  body  swings  so  as  to  straighten 
out  the  curves. 

Sit  behind  the  patient,  fix  her  thighs  with  your  knees,  while  she 
holds  both  arms  above  the  head  and  bows  toward  the  floor,  keep- 
ing her  knees  stiff  while  you  keep  her  ribs  as  straight  as  possible 
with  your  hands. 

With  the  arm  of  the  concave  side  across  the  top  of  the  head, 
and  the  arm  of  the  convex  side  around  in  front  of  the  abdomen, 
the  patient  bends  to  the  convex  side  through  the  ribs  and  not 
through  the  waist. 

The  patient  sitting  with  the  back  toward  the  surgeon,  the  latter 
pushes  one  hand  against  the  most  prominent  part  of  the  convexity, 
and  with  the  other  hand  passed  around  the  shoulder  of  the  concave 


LATERAL    CURVATURLS   OJ'     LJII-:  SPINE 


163 


side,  straightens   out   tiie   curve   as   much   as   possible,  the  hand  on 
the  "bulge"  acting  as  a  fulcrum  in  straightening  the  curve. 

The  patient  sits  on  a  stool  in  front  of  the  surgeon,  who  fixes  the 


Fig.  185. — Elastic  Strip  witli  Handles. 


Fig.  186. — Exercise  for  Strengthening  the  Back 
Muscles. 


li 


Fig.  187. — Exercise  for  Back  and  Abdominal  Muscles. 


Fig. iS 


-Exercise  for  Gluteal  and  Back 
Thigh  Muscles. 


Fig.  iSg. — E.xercise  for  Trapezius  and  Back 
^Muscles. 


pelvis  with  his  knees.  The  patient  then  twists  the  projecting 
shoulder  to  the  front,  while  the  surgeon  holds  the  elbows,  which 
are  at  right  angles  to  the  trunk,  the  hands  being  behind  the  head, 


164 


ORTHOPEDIC  SURGERY. 


and  makes  resistance.  In  the  same  position  the  patient  swings 
forward  and  back,  swinging  through  the  hips,  keeping  the  back 
stiff  and  "not  bending  in  the  waist. 

The  patient  pushes  in  the  ribs  on  the  convex  side  with  the  hand, 
and  pushes  up  with  the  hand  on  the  concave  side,  the  same  as 
when  standing.  She  also  Hfts  the  arm  of  the  concave  side  at  right 
angles  with  the  body  while  holding  a  weight. 

Where  gymnastic  appliances  can  be  had  they  will  be  found  of 
help.  An  endless  variety  of  these  can  be  employed,  but  the  accom- 
panying will  serve  as  the  simplest  and  in  the  reach  of  those  need- 


FlG.  191. 
Figs.  190,  191. — Sayre's  Exercises  for  Lateral  Curvature. 


ing  home  gymnastics.  Efficient  home  appliances  can  be  made  by 
the  use  of  rubber  exercising  tubes,  which  may  be  had  at  any  estab- 
lishment for  furnishing  rubber  goods.  Better  than  these  are  the 
weight  and  pulley  appliances  which  can  readily  be  procured.  The 
exercises  should  be  such  as  develop  the  muscles  of  the  back,  in- 
cluding the  neck;  the  glutaei  muscle  and  muscles  about  the  hip 
usually  also  need  exercising,  and  the  abdominal  muscles  also  in 
many  cases  (Figures  185,  186,  187,  188,  189). 

Suspension  as  a  means  of  muscular  exercise  is  in  all  probability 
of  little  value,  as  the  muscles  which  are  brought  into  play  are 
chiefly  the  arm  muscles.  The  temporary  relief  of  the  superincum- 
bent weight  which  is  afforded  by  suspension,  may  correct  the  curve 


LATERAL    CURVATURI'.S   OF    TJ/L  S/'/NL. 


i6; 


in  a  measure,  but  the  effect  cannot  be  lasting.  Suspension  will, 
however,  help  to  relieve  for  a  while  in  some  severe  cases  of  lateral 
curvature    the    sense   of    discomfort    caused   by   badly   distributed 

weight  falling  upon  a  distorted  s[jine. 
The  same  may  be  said  of  trapeze  and 
ring  exercises. 

Gymnastics,  as  ordinarily  prescribed 
for  lateral  curvature  in  gymnasia, 
consists  in  trapeze  and  hanging,  ring  exercises. 
Of  these  the  same  can  be  said  as  of  ordinary 
suspension,  viz.,  that  they  temporarily  correct 
faulty  attitudes  without  strengthening  the  muscles 
which  physiologically  are  needed  to  hold  the  trunk 
erect.  In  prescribing  exercises  it  is  rarely  practic- 
able to  strengthen  in  double  curves  and  in  most 
single  curves  the  muscles  of  the  convexity  without 
giving  some  exercise  to  those  of  the  concavity. 
It  is  more  practicable  to  oblige  the  patient  to 
assume  the  most  erect  attitude  possible  and  ex- 
ercise the  large  muscles  of  the  back  in  this  atti- 
tude. This  can  be  done  by  rubber  exercising 
tubes  or  better  by  the  simple  weight  and  pulley 
appliances.  A  few  light  dumb  bells,  and  a  few 
uprights,  can  be  made  to  constitute  a  useful  gym- 
nasium. 

The  muscles  of  the  lower  parts  of  the  back  will 
be   found   particularly   weak   in   most   feeble  chil- 
dren, and  this  is  frequently  a  cause  of  faulty  attitude. 


Fig.  192. — Self-suspend- 
ing Appliance. 


Mechanical  Method  of  Treatment. 


The  mechanical  means  used  are  for  the  purpose  of  either  {a) 
limiting,  checking  or  preventing  faulty  attitudes ;  {b)  for  exerting 
direct  pressure  upon  the  projecting  ribs  or  hip ;  or  for  (V)  abso- 
lutely untwisting  the  curves. 

To  understand  the  first  it  is  desirable  to  bear  in  mind  the  faulty 
attitudes  most  frequently  assumed  by  patients  with  flexible  lateral 
curves,  as  follow^s:  (i)  the  elevation  of  the  shoulder,  the  dropping 
of  a  shoulder;  (2)  the  tilting  of  the  pelvis,  raising  one  hip;  (3")  lean- 
ing the  trunk  to  one  side. 

The  appliances  used  vary  in  effectiveness  from  simple  straps  or 
springs  to  fixed  corsets  or  heav}-  braces. 

(i)  For  the  first  purpose,  that  is,  prevention  of  the  elevation  of 


1 66 


ORTHOPEDIC  SURGERY. 


the  shoulder,  a  suitable  shoulder-strap  will  be  sufficient.  This  can 
be  furnished  by  an  ordinary  cloth  or  soft  leather  strap  which,  pass- 
ing around  the  elevated  shoulder  above,  is  buckled  below  to  a  belt 


Fig.  193.— Seat  Elevated  on  One  Side  for  Changing 
Lumbar  Curves. 


Fig.  194. — Strap  for  Correcting  Elevation  ot  one 
Siioulder. 


which  is  kept  down  by  straps  secured  to  the  stockings.  (2)  Ordi- 
narily, in  light  cases,  the  prevention  of  the  raising  of  one  shoulder 
will  check  the  dropping  of  the  other.     If,  however,  it  is  not  suffi- 


Fig.  195. — Crutch  under  Arm. 


Fig.  196. — Volkmann's 
Oblique  Seat. 


Fig.  197. — Bandage  Swathe  in 
Lateral  Curvature. 


cient,  a  simple   crutch   can   be   employed  in   connection   with   the 
shoulder  strap  to  the  opposite  shoulder. 

For  prevention  of  tilting  of  the  pelvis  the  seat  higher  at  one 
side,  so  often  recommended,  will   be   found  of  some  use;    it  has 


LATERAL    CURVATURI'S   ()/•     TIfK  SI' /NIC.  1^7 

little  influence  on  the  upper  or  middle  dorsal  curve,  but  it  is  un- 
questionably of  use  in  cases  of  lower  dorsal  or  lumbar  curvatures. 

More  easily  carried  about  than  a  cushion  is  a  thick  pad  of  sad- 
dler's felt,  which  can  be  worn  (secured  to  the  waistband  and 
drawers  under  the  skirts)  on  one  buttock. 

Mr.  Barwell  has  recommended  the  use  of  ela.stic  bands  wound 
about  the  body  so  as  to  exert  pressure  on  the  desired  points.  They 
can  be  made  to  be  of  use  in  some  instances  to  check  faulty  atti- 
tudes. 

Barwell's  method  has  been  recommended  by  Dr.  Sayre  in  cer- 
tain cases.  This  method  has  lately  been  advocated  by  Fischer' 
who  applies  it  in  the  following  way:  A  band  is  placed  around  the 
shoulders  like  a  figure  of  8,  bandages  crossing  behind  and  connected 
to  an  elastic  strap  which  passes  downward  from  the  right  side  and 
forward  over  the  breast  and  belly  to  a  perineal  band  passing  around 
the  upper  part  of  the  left  thigh. 

In  this  way  the  right  shoulder  will  be  pulled  forward  and  down, 
and  the  left  hip  up — as  is  desired  in  the  correction  of  the  ordinary 
form  of  lateral  curvature.  If  the  curvature  is  of  the  opposite  type, 
the  straps  should  be  placed  pulling  from  the  left  instead  of  from 
the  right  shoulder  and  to  the  right  instead  of  the  left  hip,  and  if 
the  curve  is  a  single  instead  of  a  double  curve,  namely,  if  the  right 
shoulder  is  raised  and  the  right  hip  lowered,  the  strap  should  pass 
around  the  front  of  the  body  and  the  left  side  and  be  connected  to 
a  perineal  band  on  the  right  thigh. 

Corsets. — Corsets  of  some  sort  have  always  formed  a  common 
mode  of  treatment  in  lateral  curvature. 

Where  the  faulty  attitude  is  one  of  leaning  to  the  side,  lateral 
supports  of  some  sort  are  of  course  needed.  Many  different  varie- 
ties of  corsets  are  in  vogue — ^plaster-of-Paris  jackets  and  their  sub- 
stitutes, glue,  felt,  silicate  of  potash,  wood  pulp,  woven  wire,  leather 
made  on  moulds  taken  from  the  jackets,  and  cloth  corsets  rein- 
forced by  steel.  In  choosing  the  proper  corset  one  has  to  be 
guided  not  only  by  the  medical  conditions  of  the  case,  but  by  the 
circumstances  of  the  patient,  and  the  importance  of  sightliness  and 
comfort,  as  well  as  of  ef^ciency.  The  matter  of  personal  custom 
of  the  surgeon  often  dictates  the  choice  of  the  material  employed. 
Leather  corsets,  formed  by  being  stretched  on  moulds  of  plaster 
jackets,  the  leather  being  reinforced  by  steel  strips,  will  be  found 
efificient  and  convenient.  In  light  cases  the  leather  corset  need 
not  completely  encircle  the  trunk,  but  may  simply  be  made  in  two 
lateral  halves,  connected  by  lacings  or  straps. 

*  Centralblatt  f.  Chirurgie,  24,  p.  17. 


i68 


OR  THOPEDIC  S  URGER  V. 


Leather  corsets  may  be  furnished  with  broad  inner  leather  strips 
which,  sewn  at  one  end  to  the  inner  side  of  the  corset,  pass  through 
openings  in  the  corset  and  are  tightened  and  buckled  into  straps 


Fig   198  — Swathe  in  Lateral  Curvature. 


Fig.  igg. — Corset  with  Straps  for  Lateral  Pressure. 


on  the  side  of  the  corset,  so  that  tightening  these  straps  exerts 
lateral  pressure. 

The  place  on  the  corset  for  the  re-enforcement  by  steel  strips 
varies  in  a  measure  in  each  case,  but  they  should  be  so  placed  as 


Fig.  200.— Corset  with  Straps  for  Lateral     Fig. 
Pressure.     Cross  section. 


Di. — Diagram  of  Plaster 
Jacket. 


Fig.  202. — Slipping  of  Plaster 
Jacket. 


to  check  the  dropping  of  the  shoulder  if  there  is  a  tendency  to  this, 
as  well  as  to  check  a  habit  of  bending  the  spinal  column  to  one 
side.  Lateral  supports  should  be  as  low  on  the  side  of  the  pelvis 
as  possible. 


LATERAL    CURVATURES   OE    TJIE  S/'/NE 


1O9 


Corsets  of  this  sort,  or  of  any  sort,  are  incaijable  of  entirely  pre- 
venting leaning  to  one  side.  They  serve  rather  as  checks  or  re- 
minders. As  a  type  of  the  stiffest  corsets  the  j^Laster-of-Paris 
jacket  may  be  taken.  But  it  will  be  seen  that  although  the  trunk 
may  be  made  straight  by  suspension,  and  a  plaster  jacket  applied 
on  a  patient  in  this  position,  it  is  impossible  to  prevent  a  certain 
amount  of  slipping  of  the  corset  on  the  patient.  If  the  corset  slips 
upward,  or  if  the  pelvis  alters  its  position,  the  bearing  of  the  corset 
on  the  pelvis  is  loosened,  and  the  corset  tips  and  is  pressed  to  the 
side  by  the  trunk. 

This,  of  course,  is  also  true  if  the  corset  is  loosened  or  is  made  of 
a  less  stiff  material. 

Besides  this  objection  to  the  use   of  plaster  jackets,  it  can  be 


Fig.  203. — Removable  Corset. 


Fig.  204. — Ambroise  Fare's  Beaten  Brass  Jacket. 


stateri  that  the  method  cannot  be  relied  upon  as  the  proper  method 
of  treatment  in  lateral  curvature  in  all  stages. 

The  objections  against  the  use  of  immovable  plaster  jackets  have 
been  forcibly  expressed  by  Mr.  Adams.'  Plaster-of-Paris  jackets, 
he  thinks,  fail  as  a  curative  agent ;  the  gain  in  height  by  extension 
is  quickly  lost ;  the  spinal  muscles  are  weakened,  and  gymnastic 
exercise  is  impossible ;  respiratory  movements  are  restrained,  and 
active  exercise  prevented ;  the  treatment  is  unnecessary  at  night, 
and  bathing  is  interfered  with.  Poroplastic  jackets,  being  remov- 
able, are  free  from  the  disadvantages  of  plaster,  and  in  many  cases 
of  incurable  curvature  serve  as  a  light  retentive  support.  Mr. 
Adams'  objections  do  not  apply  to  the  use  of  removable  plaster 
corsets  (corsets  split  at  the  front),  these,  however,  are  not  as  dur- 
able as  those  made  of  felt  or  leather,  silicate  or  glue. 


Medical  Times  and  Gazette,  June  5th,  1880,  page  623. 


I/O 


ORTHOPEDIC  SURGERY. 


"Noble  Smith,  in  speaking  of  the  treatment  of  lateral  curvature, 
records  himself  as  not  in  favor  of  the  perforated  felt  jacket. 

"(i.)  Because  felt  jackets  compress  the  walls  of  the  thorax,  and 
thus  interfere  with  respiration. 


Fig.  205. 


Fig.  206. 


Fig.  207. 


"  (2.)  Because  felt  jackets  do  not  thoroughly  control  the  upper 
part  of  the  spine, 

"(3.)  Because  the  use  of  such  corsets  hinders  the  free  develop- 
ment of  the  dorsal  and  other  muscles. 


Fig.  208. 


Fig.  209. 
Figs.  205  to  210. — Beely's  Corset. 


Fig. 


"(4.)  Because  he  finds  it  better,  if  a  support  is  needed,  to  use  a 
light  instrument  which  does  not  interfere  with  muscular  exertion, 
but  which  acts  as  a  support  directly  the  muscles  become  too  tired 


LATERAL    C (./ A' V A T U ALCS   ()/••    VJ/JC  SJ'JXE 


171 


to  keep  the  spine  in  an  uprij^dit  ])osition,  and  which  prevents  the 
subsidence  of  the  spine  into  abnormal  curves." 

It  may  be  added  that  the  use  of  corsets  in  lateral  curvature  is 
as  old  as  Ambroise  Pare — the  accompanying  cut  representing  the 
beaten  brass  corsets  used  by  him  (Fig.  204). 

Corsets  should  extend  well  down  on  to  the  hips  for  the  purpose 
of  securing  a  firm  hold  on  the  pelvis;  even  then   it  is  difficult  to 


A.  B. 

Fig.  211  A  and  211  B. — Stiffened  Cloth  Corset  Applied  to  a  Severe  Case. 

entirely  prevent  tilting  of  the  jackets  and  leaning  to  the  side,  as  has 
been  shown  above. 

The  accompanying  illustrations  shows  Beel}-'s  corset,  which  may 
serve  as  a  good  type  of  the  light  corset-form  of  appliance.  This 
needs  no  description  beyond  the  statement  that  it  is  made  of  stout 
cloth  strengthened  by  strips  of  tempered  steel  and  aided  by 
straps  (Figs.  205-210). 

Flexible  corsets  can  be  made  of  woven  wire,  or  brass  wire  twisted 
spirally. 

Corsets,  as  has  been  said,  can  be  made  readily  by  modelling  from 


172 


ORTHOPEDIC  SURGERY. 


moulds  taken  from  plaster  jackets,  applied  to  patients  suspended 
or  in  a  corrected  position. 

Casts  of  the  trunk  can  also  be  made  by  inclosing  the  trunk  in  a 
hard-rubber  bag,  into  which  wet  plaster-of-Paris  is  poured. 

The  ordinary  method  of  applying  a  plaster  jacket,  with  the  self- 
suspension  of  the  patient,  aided  perhaps  by  an  appliance  for 
steadying  the  pelvis,  will  be  found  most  convenient. 

Mechanical  Appliances. — Besides  the  various  forms  of  corsets,  a 
large  number  of  heavier  appliances  have  been  in  use  designed  to 
exert  pressure  upon  the  projecting  ribs  of  the  trunks  and  to  im- 
prove the  figure. 


Fig.  212.  Fig.  213.  Fig.  214. 

Figs,  212,  213  and  214. — Method  of  taking  a  Plaster  Cast  of  the  Trunk  without  Bandage. 

These  supports  -have  fallen  into  disrepute  at  present,  largely,, 
perhaps,  because  too  much  was  expected  from  them,  and  as  they 
have  fallen  short  in  actual  accomplishment,  are  cumbersome  and 
expensive. 

These  appliances  cannot  be  expected  to  untwist  a  rotated  spine. 
They  work  at  a  mechanical  disadvantage  in  that  one  of  the  chief 
factors  in  causing  the  rotation,  viz.,  the  superincumbent  weight, 
is  not  relieved  during  the  greater  part  of  the  day.  Pressure  also  is 
applied  not  directly  upon  the  spinal  column,  but  on  the  ribs,  and 
it   has   been   urged    that   such   pressure   will    simply  increase    the 


LATERAL    CURVATURliS   OJ''    /'//A'  S/'/NF. 


173 


amount  of  motion  in  the  costo-vcrtcbral  articulation  without  affect- 
ing the  spine.  But  as  the  chief  deformity  h'es  in  the  projection 
of  the  ribs,  anything  which  will  check  or  diminish  the  amount  of 
this  projection,  will  be  of  advantage. 

In  any  appliance  which  is  designed  to  exert  pressure  ujjon  or 
correct  the  attitude  of  the  erect  trunk,  it  is  essential  that  the 
base  of  the  support  be  fixed.  This  can  be  done  in  several  ways : 
1st,  by  straps  connected  with  the  base  of  the  support,  passing 
under  the  perineum  and  secured  in  front.  The  support  is,  there- 
fore, checked  if  it  tilts  to  the  side. 

2d.  By  straps  at  the  base  of  the  support  which  pass  from  front 
to  rear  on  both  sides  over  the  rim  of  the  pelvis  and  prevent  tilting 
of  the  appliance. 

3d.  By  attaching  to  the  pelvic  band  of  the  support  pieces  of  steel 
which  pass  down  the  outer  side  of  the  thighs  and  are  strapped  to 
them  at  the  lower  end,  and  at  the  upper  end  are  secured  to 
the  pelvic  band  by  a  strong  joint.     Flexion  of  the  thighs  is  possi- 


FiG.  215. — Points  for  Lateral  Pressure  in  Deformity  of  Thorax. 

ble,  but  any  leaning  to  the  side  of  the  appliance  is  checked  in  pro- 
portion to  the  strength  of  the  steel  and  the  length  of  the  lower 
lever  applied  to  the  thigh. 

This  fact  is  overlooked  in  a  large  number  of  appliances  as  will 
be  seen  in  many  of  the  illustrations.  It  is  manifest  that  unless 
this  fact  is  borne  in  mind,  lateral  pressure  simply  tilts  the  appli- 
ance without  affecting  the  curve  of  the  spine.  In  fact  it  may  be 
said  that  unless  the  pelvic  band  is  thoroughly  prevented  from 
tilting,  the  apparatus  is  useless. 

If  the  pelvic  band  is  secured  as  far  as  possible  from  tilting,  a 
base  line  is  secured,  steel  arms  can  pass  upward  to  the  side  of  the 
trunk,  and  serve  either  as  a  point  of  attachment  for  straps,  or  for 
movable  plates  adjusted  by  a  screw  pressure. 

The  points  for  lateral  pressure  and  counter-pressure  vary  in  each 
case,  and  with  each  curve.  The  accompanying  diagram  (Fig.  215) 
shows  the  points  of  pressure  and  counter-pressure  in  an  extremely 
deformed  thorax,  and  if  there  is  also  a  tendency  for  the  trunk  to 
lean  to  the  side,  a  side  pressure  is  also  needed.     Pressure  may  be 


174 


ORTHOPEDIC  SURGERY. 


needed  on  one  side  in  the  upper  part  of  the  thorax  and  in  a  differ- 
ent direction  in  the  lower  portion  of  the  trunk. 

In  describing  the  great  variety  of  apphances  recommended  and 


Fig.  2i6.— Appliance  with  Lateral  Screw  Force.  Fig.  217. — Appliance  with  Screw  Force  and  Plates 

for  Lateral  Pressure. 

in  use,  it  is  impossible  to  describe  the  details  in  all.     They  may  be 
classified  as  follows: 

I.  Those  exerting  force  by  means  of  screws  and  levers. 


Fig.  218.— Jointed  Back  Upright. 


Fig.  219. — Appliance  with  Screw  at  Base  for 
Altering  Angle  of  Upright. 


2.  Those  working  by  means  of  straps  and  buckles. 

3.  Those  acting  on  the  principle  of  leverage. 

Appliances  with  Screw  Force.  —  Uprights  are  connected  with  a 


LATERAL    CURVATUNLS   ()/■'    77/ JC   .V/'/yW:. 


175 


pelvic  or  waist  band,  and  so  adjusted  tliat  by  means  of  a  screw 
and  worm  the  angle  of  the  uprights  can  be  altered. 

It  is  of  course,  as  has  been  said,  essential  that  the  pelvic  band  be 
firmly  secured,  and  this  can  be  done  by  means  of  perineal  straps, 
straps  over  the  pelvis,  or  by  connecting  the  band  with  steel  rods 
which  are  fastened  to  the  thighs.  In  the  accompanying  illustration 
straps  over  the  pelvis  are  those  relied  upon  to  prevent  tilting. 

An  example  of  this  form  of  appliance  is  given  in  the  accompany- 
ing illustration  (Fig.  216). 

aa  is  a  pelvic  band  furnished  with  straps  which  pass  over  the 
crest  of  the  ilium  and  prevent  dropping  of  one  side  of  the  pelvic 
band,     c  is  an   upright  for  the   back  to  which  are  attached   arms 


Fig.  220. — Lateral  Pressure  by  Plate 
and  Strap. 


Fig.  221. — Appliance  for 
Fixation  by  Strap. 


Fig.  222. — Appliance  for  Pressure 
by  Straps. 


moved  by  a  worm  and  screw  and  furnished  with  plates  at  dd. 
Crutches,  bb,  which  pass  under  the  axilla  are  designed  to  steady 
the  appliance. 

The  second  illustration  shows  a  more  powerful  appliance  fur- 
nished with  two  uprights. 

Still  another  form  is  represented  in  Fig.  218,  where  the  adjust- 
ment is  secured  in  a  less  expensive  way.  Instead  of  the  worm  and 
screw,  the  upright  is  broken  and  parts  can  be  moved  laterally  by 
means  of  a  pivot,  and  secured  in  the  altered  position  by  means  of 
a  set  screw. 

In  another  form  the  lateral  motion  is  secured  by  means  of  a  long 
screw  on  the  pelvic  band. 

The  number  of  appliances  which  can  be  devised  on  the  principles 


176 


ORTHOPEDIC  SURGERY. 


of  screw  force  is  manifestly  very  great.  The  simplest  form  will  be 
the  best,  provided  it  is  also  efificient. 

Appliances  with  Straps. — Forms  of  appliances  attempting  to 
secure  correction  hy  means  of  lateral  pressure  through  straps  or 
lacings  connected  with  an  immovable  upright,  are  usually  lighter 
than  those  trusting  to  screw  power.  They  are  also  simpler,  but 
the  power  is  not  as  carefully  regulated  and  adjusted.  The  accom- 
panying illustrations  show  the  various  vyays  in  which  straps  should 
be  adjusted. 

Appliances  Relying  on  Leverage. — Lateral  pressure  can  be  exerted 
by  means  of  the  principle  of  leverage  as  is  seen  in  the  accompany- 


FiG.  223. — Appliance  for 
Pressure  by  Strap. 


Fig.  224. — Appliance  for  Pressure  by 
Straps. 


Fig.  225. — Appliance  for  Lateral 
Pressure  by  Straps. 


ing  figure.  This  appliance  is  more  useful  in  preventing  faulty  atti- 
tudes than  in  correcting  existing  deformity. 

Another  form  of  appliance  is  made  by  which  pressure  upon  the 
projection  ribs  can  be  effected  on  the  principle  of  leverage  in  the 
following  way. 

Arms  are  constructed  so  as  to  straddle  the  pelvis  on  each  side. 
The  two  arms  are  connected  behind  by  a  joint  and  clasped  in 
front;  on  both  sides  at  the  bottom  these  arms  are  furnished  with 
straps,  which  press  upon  the  sides  of  the  hips.  At  the  top  one  of 
these  arms  is  furnished  with  a  pad  plate,  on  tightening  the  hip 
strap  on  that  side  lateral  pressure  can  be  exerted.  A  light  crutch 
can  be  furnished  to  the  arm  on  the  other  side. 

It  must  be  admitted  that  the  amount  of  benefit  as  yet  obtained 
by  heavy  appliances  is  small.  As  a  means  of  correction  they  can 
hardly  be  called  successful,  and  for  checking  an  increase  of  the 


LATERAL    CURVATURLS   OF    THE  SPJNE. 


177 


curve  they  may  be  of  assistance,  if  tliorouj^hly  carefully  ai^plied  and 
conscientiously  worn  for  a  lon^  period. 

The  proper  adjustment  and  choice  of  appliance,  the  judgment 
as  to  when  it  is  to  be  worn  and  the  length  of  time  for  the  use  of 
the  appliance  are  matters  on  which  authorities  differ.  No  fixed 
rules  can  be  prescribed  and  the  cases  need  to  be  looked  upon  indi- 
vidually. 

MetJwdical  Forcible  Correction. — Lorenz,  in  a  valuable  work  upon 
the  subject,  has  suggested  the  advisability  of  correcting  the  dis- 
tortion of  lateral  curvatures  by  twisting  the  patient  over  a  pad- 


FiG.  226. — Appliance  for  Lateral  Pressure. 


Fig.  227. — Lever  Principle  for  Lateral  Pressure. 


ded  bar,  for  several  weeks,  daily.  This  method  is  a  tedious  one, 
but  if  tried  it  will  be  found  to  be  the  most  efficient  means  for  cor- 
rection in  cases  with  slight  osseous  curves ;  but  is  manifestly  un- 
suited  for  advanced  cases. 

The  arrangement  depicted  in  the  accompanying  diagram,  which 
is  slightly  modified  from  the  appliances  described  by  Lorenz  and 
Beely,  will  be  of  service.  Daily  use  of  this  Avill  be  found  to  cor- 
rect distortions  which  simple  suspension  or  recumbency  will  not 
correct.  The  effect  of  sucli  correction  is  only  temporary,  unless 
the  gain  be  improved  upon  by  fixative  appliances.  This  Lorenz 
reports  to  have  done  successfully.  Where  correction  is  possible  it 
12 


178 


ORTHOPEDIC  SURGERY. 


is  evident  that  this  can  be  done  to  the  best  mechanical  advantage 
if  the  exciting  cause,  superincumbent  weiglit,  is  removed.  Suspen- 
sion, as  has  already  been  said,  accomplishes  this;  but  the  effect  of 
this  mode  of  correction  cannot  be  localized.  By  Lorenz's  method 
this  is  more  readily  done. 

If  the  spinal  column  be  arched  backward  the  rotation  can  be 
made  to  disappear,  and  if  slight  bony  or  ligamentous  change  pre- 
vents the  entire  disappearance  of  the  rotation,  force  can  be  applied 
to    greater    mechanical    advantage    when  the    patient    is    recum- 


FiG.  228. — Lorenz  Method  of  Correction  by  Pressure.        Fig.  229. — Twisting  Appliance  for  Correction  of 

Lateral  Curvature. 

bent  or  the  weight  is  taken  off  the  spinal  column,  than  when  the 
patient  is  erect,  by  means  of  appliances. 

The  treatment  of  lateral  curvature  in  the  early  portion  of  the 
stage  of  development  should  be  therefore  an  attempt  to  increase 
the  backward  flexibility  of  the  spinal  column,  especially  in  that 
portion  where  the  curve  is  the  most  pronounced. 

In  short,  there  should  be  in  these  cases  of  lateral  curvature  an 
attempt  to  develop  backs  similar  to  those  seen  in  the  class  of  gym- 
nasts and  contortionists,  known  as  backward  contortionists,  who 
have  developed  an  unusual  amount  of  backward  flexibility  of  the 
spinal  column. 

In  addition  to  the  appliance  employed  by  Lorenz  is  a  simpler 
one,  which  can  be  used  by  patients  at  their  homes. 


LATKKAI.    CUKVyV/'l/A'/CS   i)l'     Till':  SPINE. 


'79 


The  appliance,  which  should  be  placed  upon  a  flat  lounge,  con- 
sists of  a  board  a  little  wider  than  the  patient  and  long  enough  to 
hold  the  greater  part  of  the  patient's  trunk  when  recumbent.  At 
the  end  of  the  board  should  be  a  wooden  bar  covered  with  a 
padded  leather  pillow.  This  bar  should  revolve  on  two  pivots 
secured  to  the  board,  and  the  patient  should   lie  with  his  shoulders 


Fig.  230.' — Twisting  Appliance  for  Methodical  Correction  of  Lateral  Curvature. 

upon  this  padded  bar  Avhich  should  be  raised  about  ten  inches  from 
the  plane  of  the  board.  An  assistant  should  gently  pull  the  patient 
so  that  the  shoulders  will  project  beyond  this  roller,  and  should 
then  direct  and  assist  the  patient  to  raise  the  arms  above  the  head 
and  bend  the  head  and  arms  and  upper  portions  of  the  neck  and 
back,  as  far  backward  as  possible.  The  patient  should  then  be 
directed  to  take  deep  inspirations  and  expand  the  chest  as  far  as 
he  is  able:   he  should  now  turn  so  as  to  lie  chiefly  upon  the  pro 


Fig. 


-Side  Twisting  of  the  Spine  in  iNIethodical  Correction. 


jecting  shoulder,  the  assistant  pressing  upon  the  projecting  ribs  in 
front  and  the  patient  breathing  as  deeply  as  possible.  If  the  chief 
curve  is  in  the  lumbar  region,  the  lower  portion  of  the  back  should 
be  placed  upon  this  roller,  the  legs  held  down  by  an  assistant,  and 
the  patient  directed  to  bend  backward  as  far  as  he  can  conven- 
iently do  so. 


i8o 


ORTHOPEDIC  SURGERY. 


Forcible  rectification  under  anaesthesia  is  a  method  which  has 
been  recommended,  but  not  appHed. 

Mr.  Barwell  {Lancet,  April  27th,  1889,  p.  831)  recommends  a 
method  of  forcible  correction  by  means  of  exercising  with  straps, 
which  he  terms  rachilysis.  The  method  is  a  practical  one,  but 
hardly  as  efficient  as  that  of  Lorenz. 

Fischer  has  also  advocated  much  the  same  plan,  recommending 
that  the  patient  should  exercise  by  wearing  weights  hung  upon  the 
neck  by  means  of  a  padded  collar,  the  patient  assuming  such 
attitudes  as  may  be  required  to  bring  the  pressure  in  a  proper 
direction. 

Lorenz  has  recommended  the  application  of  plaster  corsets  to 
patients  held  in  a  position  twisted  to  the  side,  as  is  illustrated  in 
the  accompanying  diagrams.     The  writers  have  made  a  thorough 


Fig.  232.  Fig.  233. 

Figs.  232,  233  and  234. — I.orenz'  Fixation  Plaster  Corset. 


Fig.  234. 


trial  of  this  method,  but  have  been  unable  to  satisfy  themselves 
that  it  presented  advantages  over  the  ordinary  method  of  applica- 
tion of  jackets. 

The  exact  value  of  methodical  correction  can  hardly  yet  be  de- 
termined, as  the  method  is  new,  but  from  the  cases  reported  by 
Lorenz,  it  would  seem  to  be  of  value.  This  would  be  the  opinion 
of  the  writers  from  their  experience  in  the  method. 

Operative  Measures. — No  methods  of  operative  interference  are 
of  use  in  lateral  curvature. 

Forcible  correction  under  an  anaesthetic  has  been  suggested,  but 
never  deemed  advisable.  Myotomy  and  fasciotomy,  advised  by 
Guerin,  have  not  been  accepted  as  proper  treatment. 

Sayre  and  Volkmann  have  both  performed  myotomy,  but  the 
latter  has  rejected  the  method  [Centralblatt  f,  Chir.,  No.  30,  p.  483, 
1880)  and  the  former  no  longer  employs  it. 


LATERAL    CURVATURES   Of'     THE  SEINE. 


/8f 


Correction  in  a  Recumbent  Position.     This   is  a  method   formerly 
much  employed  and  at  present  in  all  probability  too  much  neg- 


FlG.  23s.— Reclining  Couch  with  Lateral  Pressure  and  Traction. 


Fig.  237.— Reclining  Couch  with  Traction  by  Weight. 


Fig.  23S.— Side  View 


lected.  The  accompanying  picture  illustrates  forms  of  a  reclinino- 
couch  for  lateral  pressure  and  a  traction  force.  The  latter  is  0I 
httle  advantage,  except  as  a  means  of  securing  the  patient. 


I82 


OK  THOPEDIC  S  UR  GER  V. 


Spinal  couches  present  a  wearisome  method  of  treatment,  but  in 
cases  which  are  rapidly  becoming  worse,  they  offer  the  most  tho- 
rough means  of  treatment.  They  can  be  employed  for  a  certain 
number  of  hours  a  day. 


Choice  of  Methods. 


If  the  methods  of  treatment  mentioned  be  recapitulated,  they 
maybe  summarized  as  follows:  i,  postural;  2,  gymnastic;  3,  by 
recumbency;  4,  methodical  correction;  5,  mechanical.  These  are 
severally  suited  to  different  classes  of  cases,  and  the  selection  of 
the  proper  method  or  methods  will  vary  according  to  the  patient's 
condition  and  the  state  of  the  curvature. 

If  the  back  is  flexible  and  no  osseous  change  has  taken  place ;  if 
the  curvature  entirely  disappears  when  the  pa- 
tient is  recumbent  or  suspended,  and  is  appar- 
ently dependent  upon  habits  of  attitude,  stand- 
ing, or  sitting,  the  postural  method  is  applicable, 
coupled  with  careful  selection  of  school  seats, 
desks,  and  home  chairs. 

If  to  this  condition  of  habitual  faulty  attitudes, 

muscular  weakness  of  certain  groups  of  muscles 

is  added,  proper  gymnastics  should  be  employed. 

If  the  curves  are  threatening  to  increase,  and 

the  patient  gives  evidence  of  nervous  exhaus- 

^^^ ,  tion,  recumbency  for  several  hours  a  day  should 

V     «     ^F  ^^  enforced;  and  in  the  worse  cases,  recumbency 

Fig  .39  -Fixation  Board     should  be  aided  by  fixation  in  improved  position 

with  Lateral  Pressure.  by  mCanS   of   appHanCCS. 

When  the  curves  are  somewhat  fixed,  but  some  flexibility  still 
remains,  the  method  of  methodical  correction  carried  out  for  sev- 
eral months  will  be  found  helpful,  in  addition  to  gymnastics  and 
postural  exercises. 

Of  appliances,  removable  plaster  jackets  or  corsets  of  that  type, 
will  be  found  the  most  available,  as  they  are  of  service  in  prevent- 
ing or  checking  the  assumption  of  faulty  attitudes,  and  as  checks 
to  torsion  and  growing  out  of  the  ribs. 

Appliances,  however,  should  always  be  regarded  as  to  be  supple- 
mented by  gymnastic  treatment,  and  should  only  be  used  tempo- 
rarily during  the  period  of  the  greatest  increase  of  the  curves. 

It  cannot  be  asserted  that  the  use  of  appliances  or  corsets  can  in 
all  cases  be  dispensed  with.  They  are  needed  in  cases  where  the 
curve  threatens   to   increase,  and   among   negligent   people  where 


LATERAL    CURVATURES   UR    TJIR  SPINE.  183 

gymnastic  treatment  cannot  be  well  carried  (jut,  while  there  is  a 
pressing  clanger  of  increase  of  the  curve. 

Corsets  and  mechanical  appliances  necessarily  weaken  the  mus- 
cles of  the  back,  and  are  to  be  avoided  if  possible,  and  when  they 
are  used,  massage  is  advisable  in  addition  to  gymnastics. 

The  amount  of  time  needed  for  treatment  varies  necessarily.  In 
general  it  should  be  stated  that  growing  children  need  careful  in- 
spection during  growing  years.  The  inspection  need  not  be  fre- 
quent, and  will  vary  from  three  months  to  six  months  according  to 
the  rate  of  growth.  In  light  cases,  a  few  weeks'  supervision  of 
gymnastics,  followed  by  monthly  or  quarterly  inspection,  is  all  that 
is  necessary.  In  more  threatening  cases,  methodical  correction 
and  the  use  of  appliances  under  supervision  for  several  months  are 
desirable. 

In  the  severest  types  of  rigid  curves,  no  corrective  treatment  is 
advisable,  as  the  symptoms  can  be  relieved  by  stiff  corsets,  or 
suspension,  recumbency,  massage,  and  electricity. 

The  subject  of  treatment  has  been  well  summarized  by  Walsham  : 
(i)  All  lighter  cases  should  be  treated  by  gymnastics.  (2)  Appli- 
ances can  be  combined  with  gymnastic  treatment.  (3)  Even  in  the 
severer  cases  gymnastics  should  be  employed,  and  in  event  of  fail- 
ure, corsets  can  be  employed.  (4)  Corsets  alone,  however,  never 
result  in  cure,  rarely  in  improvement,  and  sometimes  do  not  pre- 
vent an  increase  of  deformity. 


CHAPTER   III. 


OTHER   AFFECTIONS    OF   THE    SPINE. 


Curvatures  of  the  Spine. — Physiological  Curvatures. — Scoliosis. — Kyphosis. — 
Round  Shoulders. — Rheumatism  of  the  Spine. — Lordosis — Weak  Spine. — 
Spondylolisthesis. — Affections  of  the  Thorax. — Malignant  Disease  of  the 
Spine. 

Physiological  Curvatures  of  the  Spine. 

As  the  spinal  column  is  composed  of  several  segments  bound 
together  by  ligaments  and  muscles,  it  is  frequently  curved  in  a 
variety  of  ways.  The  amount  of  possible  curvature  is  checked  by 
the  shape  of  the  vertebrae,  the  length  of  the  ligaments  and  the 

tonicity  of  the  muscles,  and  this  amount 
can  be  somewhat  increased  by  practice,  as 
in  acrobats  (Thomas  Dwight,  Scribners 
Magazine,  May,  1889)  and  varies  in  degree 
and  kind  according  to  age,  occupation, 
and  physiological  capabilities. 

The  anatomical  researches  of  the  Weber 
brothers,  Henke  and  Meyer,  and  others 
have  fully  explained  the  physiological 
curves  of  the  spine,  and  little  need  be  said 
here  farther  than  to  state  that  in  infants 
the  spinal  column  is  straight.  When  the 
child  begins  to  sit,  the  back  bends,  the 
convexity  of  the  curve  being  backward, 
but  on  standing  and  walking  the  pelvis 
is  rotated  from  the  position  necessarily 
assumed  in  the  sitting  and  lying  position, 
and  the  spine  becomes  curved  forward  just  above  the  pelvis,  making 
the  so-called  hollow  of  the  back.  In  this  way  are  developed  the 
so-called  physiological  curves  of  the  spine,  which  are  constant  and 
characteristic,  but  vary  to  a  degree  according  to  the  habits,  occu- 
pation, sex,  and  shape  of  the  individual. 

The  curves  are  as  follows :  a  long  curve,  involving  nearly  the 
whole  of  the  dorsal  region,  with  the  convexity  backward  ;  above  this 
the  spine  is  bent  in  another  curve  in  the  cervical  region  with  the 
convexity  forward,  and  in  the  same  direction  in  the  lumbar  region. 


Fig.  240. — Physi- 
ological Curves  of 
Spine. 


Fig.  241. 


OTHER   AFJ'l'lCTlONS    Ol'     77 /K  S/'/N/C. 


185 


The  long  dorsal  curve  becomes  changed  and  exaggerated  in 
persons  who  habitually  bend  forward  from  habit  or  occupation, 
and  the  hollow  of  the  lower  part  of  the  back  varies  greatly  in  dif- 
ferent individuals. 

The  effect  of  superincumbent  weight  upon  the  spinal  column  is 
to  exaggerate  the  physiological  curves,  and  as  is  well  known,  there 
is  a  diminution  in  the  height  of  the  body  at  the  end  of  the  day  of 
from  thirteen  to  fourteen  millimetres. 

As  a  proof  that  muscular  action  does  not  cause  the  physiological 
curves  of  the  spine,  a  rare  instance  may  be  cited  of  that  condition, 
where  owing  to  malformation  or  disease,  the  acetabulum  was  want- 
ing, and  the  weight  fell  upon  the  hip-joint  paced  forward  of  the  nor- 
mal position.'  In  this  case  the  pelvis  tipped  backward  more  than 
normal  and  the  lumbar  curve  was  obliterated,  so  that  the  lumbar 
region  was  filled  and  the  hollow  of  the  back  disappeared.  Mus- 
cles act  as  a  check  to  the  bending  of  the  spinal  column  and  it  is  a 
combination  of  this  with  the  fact  of  gravity  and  the  necessity  of 
keeping  the  head  erect  which  gives  rise  to  the  curves  which  are 
always  found  in  the  erect  figure. 

Muscles  weakened  either  by  disease  or  by  too  rapid  grow^th, 
which  are  unable  thoroughly  to  do  the  work  expected  of  them  do 
not  prevent  an  increase  of  these  curves.  The  same  is  true  of  cer- 
tain occupations  as  that  of  cobblers  and  tailors  as  compared  to 
that  of  soldiers.  It  will  also  be  found  that  there  is  a  difference 
in  length  of  the  spine  according  to  the  patient's  attitude,  the 
spine  being  longer  in  the  recumbent  position  that  when  standing. 
The  amount  of  this  change  will  be  seen  by  referring  to  the  ac- 
companying table  of  measurements  of  the  height  of  eleven  people 
standing,  and  their  length  when  lying  upon  the  floor  on  their  backs ; 
ten  of  these  were  adults  and  one  a  child.  The  difference  was  rela- 
tively greatest  in  the  child. 


Age. 

Height  in  Erect 

Length  in  Dorsal 

Difference. 

Position. 

Recumbency. 

I 

28 

5  ft.      8  ^  in. 

5  ft.      9  ^  in.  , 

■-|  in. 

2 

40 

6  "       I/,  - 

6"       2Je" 

H" 

3 

38 

5"       7-^i" 

5"       83!," 

1^" 

4 

15 

5"        A" 

5"       lA" 

M" 

5 

22 

5  "      S      " 

5 "   m " 

10" 
T6 

6 

29 

5"      Sif" 

5 "   9  " 

^" 

7 

30 

5"     iixr' 

6"        ^" 

A" 

8 

22 

5"     "A" 

5"    iiH" 

1*6" 

9 

31 

6  "      2      " 

6"      2if"   ' 

12    a 

10 

35 

5"      4lf" 

5  \\      S^  \\ 

A" 

II 

3i 

3"       lA" 

H" 

Result  same  in  eight  other  cases  in  which  measurements  were  not  recorded. 
^  Monks,  Boston  ]\Iedical  and  Surgical  Journal.  Nov.  iSth,  1SS6. 


l86  ORTHOPEDIC  SURGERY. 


Age. 

Erect. 

Recumbent. 

Difference. 

35    ■ 

Evening,  lo  P.M. 
Morning,    7  a.m. 

5  ft.     4H  in- 
5  "      5A    " 

5  ft.      5/^  in. 
5  "      511    " 

if' 

The  curvatures  of  the  spine  demanding  orthopedic  treatment 
apart  from  the  curvatures  from  caries  of  the  spine  already  de- 
scribed, are  of  three  kinds  : 

1.  Lateral  curvature ;  scoliosis. 

2.  Curvature  with  convexity  backward ;  kyphosis. 

3.  Curvature  with  the  convexity  forward;  lordosis. 
These  are  frequently  combined. 

Scoliosis. 

Lateral  curvature  of  the  spine  has  been  considered  in  the  pre- 
ceding chapter,  and  will  not  be  discussed  here. 

Kyphosis. 

The  curvature  of  the  spine  with  the  convexity  backward  (kypho- 
sis) is  either  the  physiological  curve  increased  to  an  unusual  degree, 
or  it  represents  a  curve  incident  to  pathological  states. 
.  The  first  variety  usually  is  situated  in  the  upper  part  of  the 
spine  between  the  shoulders,  and  constitutes  what  is  ordinarily 
termed  round  shoulders.  This  is  due  either  to  a  habitual  bending 
forward  of  the  head  and  neck,  or  in  addition  to  this,  to  a  position 
of  the  shoulder  blades,  which  are  dropped  forward  instead  of  being 
held  back  nearer  to  the  spine  as  in  the  normal  position.  Ordinarily 
this  condition  is  the  result  of  a  relative  muscular  weakness,  the 
head  being  bent  forward  from  a  diminished  muscular  tonicity.  This 
condition  of  things  is  seen  more  frequently  in  rapidly-growing  chil- 
dren. The  curvature  may  also  result  from  habit  or  occupation  in 
perfectly  healthy  persons,  as  the  round  shoulders  of  cobblers  or 
tailors. 

Another  and  marked  form  is  seen  in  the  rounded  shoulders  so 
common  in  old  age,  when  with  the  general  wasting  of  the  tissues, 
partial  absorption  of  the  intervertebral  discs  takes  place,  and  the 
vertebral  column  assumes  a  greater  curve  in  the  dorsal  region. 
This  is  noticed  in  nearly  all  persons  who  reach  sufficient  age  to 
establish  the  process  of  the  absorption  of  subcutaneous  fat  and  the 
general  condensation  of  tissue  characteristic  of  that  period.  The 
intervertebral  discs  in  the  dorsal  region  in  the  aggregate  are  some- 
what thicker  at  their  anterior  than  at  their  posterior  part,  so  that 
they  maintain  the  dorsal   spine  in  a  less  curved    condition    than 

'Boston  Med.  and  S.  Jour.,  Sept.  13th,  1883,  245. 


OTHIlR   affections   of    Till':  SPINE. 


187 


would  be  the  case  if  the  bones  were  in  contact  with  each  other. 
Consequently  tiie  wasting  of  these  discs  causes  {greater  dorsal  curv- 
ature. 

A  similar  dorsal  kyphosis,  associated  with  ri<^idity,  is  seen  in 
rheumatoid  arthritis  of  the  spine  due  to  a  process  similar  to  the 
senile  change  just  alluded  to. 

A  rare  form  of  kyphosis  is  seen  in  osteo-malacia,  where  the  whole 
spine  may  be  bent  so  that  it  forms  one  long  arch  with  the  convex- 
ity backward.  In  one  severe  case  examined  by  the  writers,  the 
curve  was  so  great  that  the  chin  of  the  patient  rested  on  the  um- 
bilicus. No  difificulty  is  met  in  recognizing  this  form  of  kyphosis, 
as  the  other  symptoms  of 


osteo-malacia,  the  brit- 
tleness  of  the  bones,  etc., 
make  the  diagnosis  clear. 
A  most  common  form 
of  kyphosis  is  that  seen 
in  children  with  rickets. 
This  is  usually  situated 
in  the  lower  dorsal  re- 
gion and  always  involves 
two  or  three  vertebrae. 
The  curve  is  rounded 
and  usually  disappears 
or  diminishes  as  the  pa- 
tient   lies   UDOn    the    face         Fig.  242. — Kyphosis  in  Advanced  Paralysis  of  the  Back  Muscles. 

though  this  is  not  always  the  case. 

A  very  marked  form  of  kyphosis  of  nearly  the  whole  spine  is 
sometimes  seen  in  cases  of  paralysis  of  the  back  muscles,  either 
after  anterior  polio-myelitis  or  in  the  advanced  stages  of  pseudo- 
muscular  hypertrophy  or  progressive  muscular  atrophy.  In  these 
cases'  the  patient  sits  with  the  head  resting  almost  on  the  knees 
with  the  whole  back  forming  one  curve  with  the  convexity  back- 
ward. 

The  kyphosis  of  caries  of  the  spine  has  already  been  considered. 

A  recognition  of  the  condition  of  kyphosis  presents  no  difificulty, 
and  the  recognition  of  the  causes  which  produce  the  curvature  is 
ordinarily  easy  in  the  recognition  of  the  pathological  state. 
■  Caries  of  the  spine,  cancer  of  the  spine,  infantile  paralysis,  rick- 
ets, chronic  vertebral  rheumatism,  and  arthritis,  are  all  recognizable 
affections,  and  when  kyphosis  is  present  with  these  affections,  the 
cause  is  evident,  and  kyphosis  resulting  from  different  occupations 
is  also  recognizable,  a  ready  inference  from  the  knowledge  of  the 
occupations. 


1 88 


ORTHOPEDIC  SURGERY. 


Round  Shoulders. — What  may  be  called  an  exaggerated  phy- 
siological kyphosis,  round  shoulders,  is  recognized  by  the  flexibility 
of  the  spine  and  the  evident  muscular  weakness.  The  latter  can 
be  determined  by  the  dynamometrical  muscular  tests. 

These  ^re  obtained  easily  by  the  use  of  a  spring  balance  screwed 
to  the  wall  against  which  the  patient  pulls  by  means  of  a  cord 
attached  to  a  head  cap.  The  patient  sits  on  a  stool  facing  the 
balance  and  bends  backward,  using  the  back  muscles. 

The   condition   of    round   shoulders    is  sometimes    mistaken    by 

anxious  parents  for  spinal  de- 
formity, but  is  readily  distin- 
guished from  that  by  the  differ- 
ence in  the  projection  of  the 
shoulder  blade,  and  by  the 
rounded  outline  of  the  kyphosis. 
In  high  cervical  caries,  however,  a 
condition  is  sometimes  seen  in  the 
dorsal  spine,  which  closely  simu- 
lates round  shoulders.  The  spine 
is  flexible  in  round  shoulders. 

This  condition  in  very  young 
children  has  no  especial  signifi- 
cance, but  in  older  children  it 
indicates  a  lack  of  strength  of 
the  spinal  column,  and  to  an  ex- 
tent a  predisposition  to  lateral 
curvature. 

Treatment   of  Kyphosis. — The 
forms     of     kyphosis      requiring" 
treatment  are  the  rhachitic,  and 
that  due  to  muscular  weakness. 
^_  The    kyphosis    of    caries   of    the 
lar Weakness  of  Back.  spine  has  already  been  spoken  of. 

The  kyphosis  of  rickets  is  ordinarily  in  the  lower  dorsal  region, 
and  requires  no  treatment  except  anti-rhachitic  treatment,  aftd  the 
avoidance  of  the  sitting  position  to  a  large  extent  even  in  the 
milder  cases.  In  severe  cases  of  young  children  in  the  acute  stages, 
it  is,  however,  desirable  to  oblige  the  patients  to  maintain  the 
recumbent  position,  supporting  the  back  by  a  corset  or  frame.  The 
bed  frame  described  for  Pott's  disease  is  the  most  convenient  ap- 
pliance. Light  braces  and  corsets  are  of  use  as  checks  to  increase 
of  the  curvature,  but  they  are  of  little  use  in  infants,  owing  to  the 
small  size  of  the  patients,  and  in  older  children  with  rachitic  curves 
gymnastic  exercises  are  more  suitable.     Former  orthopedic  methods 


Fig.  243. — Back  Support  Formerly  Applied  in  Muscu- 


O'/'J/JCR   AJ'I'-I<:CTI0NS   OF    77 /JC  S/'/NK. 


189 


are  exemplified  in  the  figure.  Where  supports  are  needed  tliey  arc 
of  the  same  kind  as  tliose  needed  for  the  orch'nary  round  slioidders. 
The  mechanical  and  gymnastic  treatment  needed  in  round  shoul- 
ders has  been  well  described  by  Stillmann,  of  New  York,  in  a  paper 
read  by  him  before  the  American  Orthopedic  Association.  Still- 
mann directs  that  the  patient  should  lie  upon  a  lounge  with  the 
head  and  upper  extremities  lying  over  the  end  of  the  lounge,  and 
should  bend  the  head,  neck,  and  upper  part  of  the  body  as  far 
backward  as  possible.  Dumb-bell  exercises  should  be  carried  out 
in  this  position.  Exercises  can  also  be  carried  on  by  means  of 
weights  and  pulleys,  while  the  patient  is  leaning  on  a  board  arched 
backward,  the  board  be- 
ing so  arranged  that  the 
patient  is  recumbent. 

The  lighter  cases  can 
best  be  treated  by  gym- 
nastics. For  other  cases, 
mechanical  appliances 
should  be  used  made  of 
light  steel  on  the  princi- 
ple of  the  ordinary  an- 
tero-posterior  support,  or 
in  case  the  head  is  thrust 
badly  forward,  it  should 
reach  high  enough  to 
support  a  cravat  or 
stock  which,  encircling 
the  neck,  is  fastened  be-     „  .  ^  .  „  cu    ,j    c 

'  _  fiG.  244. — Antero-posterior  I*  IG.  245. — Shoulder  Straps  to 

hind   to   the  steel    upright    Support  for  SUght  Kyphosis.         Hold  Projecting  Shoulder-blades 
i.   j-l-       u        1  A  „„  on  Jjoth  Sides. 

at  the  back.    A  very  con- 
venient and  efficient  appliance  in  all  but  severe  cases  is  found  in 
tempered  steel  uprights  which  lie  against  the  transverse  processes 
of  the  vertebrae  and  terminate  in  shoulder  loops ;  below  they  take 
their  origin  from  a  rigid  steel  waist-band. 

The  condition  of  round  shoulders  is  usually  accompanied  b}-  a 
tendency  to  allow  the  shoulder  blades  to  drop  forward;  this  can  be 
checked  by  means  of  straps  applied  as  in  the  accompanying  dia- 
gram. 

The  continued  use  of  any  supporting  appliance  Avithout  careful 
gymnastics  is  likely  to  lead  to  weakness  of  the  muscles  of  the 
back.  Mr.  Roth  has  pointed  out  another  possible  result  from 
shoulder  braces.' 


'  Trans.  Am.  Orth.  Association,  Boston,  1SS9,  vol.  i. 


IQO 


ORTHOPEDIC  SURGERY. 


"  I  have  observed  in  numerous  instances  where  shoulder-braces 
have  been  worn  for  several  months  or  longer,  and  where  from  mis- 
placed perseverance  and  severity  they  have  been  worn  extra  tightly, 
that  the  unfortunate  wearer  has  tried  to  obtain  relief    from  the 

excessive  pressure  of 
the  straps  over  the 
coracoid  process  and 
adjacent  clavicle  on 
each  side,  by  throw- 
ing the  whole  upper 
trunk  backward  by 
undue  arching  of  the 
loins,  with  the  result 
of  producing  severe 
lumbar  lordosis  in  ad- 
dition to  the    dorsal 

"Fig.  246.— Faulty  and  Correct  Position.  kyphosis      for     which 

the  apparatus  was  being  worn.  I  am  quite  aware  that  dorsal 
kyphosis  is  generally  accompanied  by  compensatory  lumbar  lor- 
dosis; but  in  these  cases  to  which  I  refer,  the  lumbar  hollow  is 
much  severer  than  usual,  and  causes  an  exaggerated  thrusting  for- 
ward and  prominence  of  the  abdomen.  Of  course  I  am  referring 
to  the  kyphosis  of  muscular  debility,  and  not  to  that  due  to  spinal 
caries.  In  spite  of  these  facts,  ninety-nine  out  of  one  hundred 
medical  men  of  the  present  day  are  in  the  habit  not  only  of  allow- 
ing but  even  of  advising  patients  to  wear  these  instruments  of  tor- 
ture. I  understand  that 
large  fortunes  are  being 
made  by  the  sale  of  those 
popular  American  and  other 
shoulder-braces  which  are 
so  largely  advertised  at  the 
present  time."  Dumb-bell 
and  weight  exercises  will 
improve  the  condition  by 
strengthening  the  trapezius 
muscle.       Care    should    be 

exercised  in  supporting   the  Fig.  247.— Faulty  and  Correct  Position. 

back  by  properly  fitting  chairs,  and  by  the   avoidance  of  faulty 
attitudes  already  mentioned  under  lateral  curvature. 

The  kyphosis  in  ostitis  of  the  spine  (Pott's  disease),  malignant 
disease  of  the  spine  and  aneurism,  is  easily  recognized  and  charac- 
teristic, and  in  all  of  these  affections  it  presents  much  the  same 
characteristics. 


OTIU'IR   A/'-FJ-:C77()NS   OJ''    7J//-:   SI' I  NIL 


191 


Another  form  of  kyphosis  is  from  chronic  rheumatic  arthritis 
of  the  spine. 

Rheumatism  of  the  Spine  (Spondylitis  Deformansj. 

Ankylosis  of  the  spine  early  follows  rheumatism  or  occurs  as  a 
manifestation  of  rheumatic  gout  (arthritis  deformans).  The  affec- 
tion is  one  which  has  attracted  little  attention,  but  which  presents 
certain  characteristic  features. 

It  occurs  as  a  complication  of  gonorrhoea  in  its  rheumatic  mani- 
festation and  separately  as  a  complication  of  arthritis  deformans. 
In  gonorrhoeal  rheumatism  the  spine  is  rarely  involved  alone,  but 
in  a  few  instances  this  condition  has  been  observed. 

In  one  hundred  and  nineteen  cases  of  gonorrhoeal  rheumatism 
collected  in  the  article  on  Rheumatisme  Blennorrhagique  ("  N. 
Diet,  de  Med.  et  Chir.,"  Blennorrhagie),  the  spine  is  not  mentioned 
as  having  been  involved.  In  the  one  hundred  and  sixteen  cases 
carefully  investigated  by  Nolen  {^DeutscJics  ArcJiiv  f.  Klin.  Med.,  No. 
8,  1882,  p.  120)  two  are  mentioned  as  having  had,  in  combination 
with  affections  of  the  other  joints,  an  arthritis  of  the  vertebrae; 
one  is  mentioned  as  having  recovered,  and  the  other  as  not  being 
entirely  well  at  the  time  that  he  passed  from  observation. 

Ferron  ("These  de  Paris,"  1868,  No.  211),  without  giving  any 
clinical  facts,  states  that  all  the  joints  of  the  body  may  be  affected, 
even  "  those  of  the  jaw  and  vertebrae." 

Instances,  therefore,  of  a  permanent  stiffness  of  the  back  from 
this  exciting  cause,  without  any  accompanying  impairment  of  the 
functions  of  other  joints,  must  be  regarded  as  exceptional. 

Chronic  rheumatoid  arthritis  of  the  spine  is  an  affection  which 
presents  the  same  features  as  the  gonorrhoeal  form  just  mentioned. 
The  spine  is  in  these  cases  oftenest  primarily  the  seat  of  the  dis- 
ease, and  the  other  joints  sometimes  become  involved  later.  In 
the  cases  seen  by  the  writers  the  patients  attacked  have  been 
young  adults  and  children.  In  this  way  it  offers  a  decided  excep- 
tion to  the  general  behavior  of  rheumatic  gout.  And  the  affection 
has  been  clearly  a  primary  ankylosing  arthritis  of  the  vertebral 
column,  accompanied  by  manifestations  of  a  disease  which  resem- 
bles rheumatoid  arthritis. 

Adams,'  in  his  classical  monograph  on  rheumatic  gout,  mentions 
spinal  rheumatism  as  occurring  in  severe  cases  affecting  other 
joints,  the  distortion  sometimes  being  so  severe  as  to  interfere  with 
locomotion. 

Annals  of  Anatomy  and  Surgery,  Brooklyn,  1SS3,  vol.  vii.,  p.  6. 


ig: 


ORTHOPEDIC  SURGERY. 


Paget  has  recently  described  a  chronic  inflammation  of  the  bones 
(Medico-Chirurgical  Transactions,  1879,  2d  series,  vol.  42,  1877,  p. 
'^'j)  which  he  has  named  osteitis  deformans  (also  called  Paget's  dis- 
ease), "  the  spine,  whether  yielding  to  the  weight  of  the  overgrown 
skull  or  by  change  in  its  own  structure,  may  sink  and  seem  to 
shorten  with  greatly  increased  dorsal  and  lumbar  curves." 

Similar  is  the  arthritis  deformante  du  rachis,  described  by  Ley- 
den,  1874,  and  by  Braun  ("Klin,  und  Anat.  Beitrage  z.  Kenntniss 
d.  Spondylitis  Deformans,"  Dr.  Julius  Braun),  and  also  in  an  arti- 
cle in  the  Transactions  of  the  London  Clinical  Society,  1879,  P-  204. 

Rosenthal  ("  Diseases  of  the  Nervous  System,"  American  trans- 
lation, 1879,  p.  225)  states  "  that  the  principal  phenomena  in  deform- 
ing vertebral  inflammation  of  a  chronic  course  (also  called  verte- 
bral gout)  consists  of  a  difificulty  in  the  movements  and  stiffness 
in  the  corresponding  vertebral  articulations  combined  with  pe- 
ripheral pains.  The  loss  of  motion  is  most  marked  in  the  cervical 
column.  Thickening  and  nodosities  are  sometimes  observed  in 
certain  parts  of  the  neck  if  the  cervical  vertebrae  are  affected,  or 
in  the  abdominal  region  when  the  lumbar  vertebra  are  involved. 
At  times  well-marked  creaking  is  observed  in  rotary  movements 
of  the  neck." 

The  deformities  of  the  vertebral  column  following  spondylitis 
deformans  may  sometimes  exercise  compression  upon  the  cord. 

Putzel  ("  Functional  Nervous  Diseases,"  p.  133)  mentions  the  fact 
that  the  affection  is  scarcely  mentioned  by  writers  on  orthopaedic 
surgery.  Two  cases  of  ankylosis  of  the  spine  with  stiffness  of  the 
other  joints  are  reported  by  Brodhurst  (Reynolds' "  System  of  Med- 
icine," vol.  i.,  960),  and  one  case  of  ankylosis  of  the  spine  is  men- 
tioned by  Delpech  ("  L'Orthomorphie  "). 

Syniptoiiis. — The  symptoms  of  the  affection  are  pain  in  the 
spine,  sometimes  aggravated  by  every  jar  and  paroxysmal  in  char- 
acter. It  is  described  as  being  very  distressing  and  these  patients 
move  with  the  greatest  possible  care  to  avoid  being  shaken.  In 
other  cases  pain  may  be  a  subordinate  symptom,  and  may  be  little 
complained  of.  Stiffness  of  the  spine  is  the  characteristic  symp- 
tom. The  normal  curves  are  slightly  exaggerated,  especially  the 
dorsal  curve,  and  perhaps  very  much  increased,  and  the  patient 
walks  somewhat  bent  over  by  the  dorsal  kyphosis  with  a  gait  some- 
what like  that  of  Pott's  disease.  In  stooping  the  motion  is  entirely 
from  the  hips.  In  lying  down  the  curves  are  not  affected  or  oblit- 
erated. In  short  the  spine  is  stiff  from  the  sacrum  to  the  occiput 
in  the  worst  cases  and  permits  no  more  motion  than  would  an  iron 
rod.  In  the  severer  cases  the  ribs  are  ankylosed  at  their  junction 
with  the  spine,  and  the  chest  wall  scarcely  moves  in  inspiration,  or 


OTiii'iR  AJ'in'icTioNS  ()]■   Tiir:  SI' INI-:. 


193 


it  may  be  entirely  stationary  and  of  course  tlie  breatln'n^^  is  wholly 
abdominal. 

The  cervical  vertebra;  are  usually  the  last  to  be  affected,  and 
motion  of  the  head  is  possible  after  the  dorsal  and  lumbar  regions 
have  become  rigid.  There  are  no  other  characteristic  symptoms 
of  the  affection. 

In  less  severe  and  advanced  cases  the  sj)ine  is  not  involved  to 
the  whole  extent,  but  marked  stiffness  without  angular  projection 
exists  in  a  portion  of  the  column. 

The  course  of  the  disease  is  chronic  in  the  extreme,  and  its 
duration  covers  many  years.  The  bone  inflammation  has  no  de- 
structive tendency  and  accomplishes  nothing  more  than  stiffen- 
ing tlie  vertebral  column.  The  impairment  of  the  general  health 
consequent  upon  this  is  generally  not  so  severe  as  one  would 
anticipate. 

The  diagnosis  of  the  affection  can  be  made  by  recognizing  the 
rigidity  of  the  entire  vertebral  column  without  the  angular  promi- 
nence of  Pott's  disease,  nor  does  the  latter  affection  so  stiffen  the 
whole  column,  but  only  the  diseased  region.  Pott's  disease  involv- 
ing the  whole  or  a  large  portion  of  the  vertebral  column  would 
soon  lead  to  very  marked  results  in  its  destructive  tendency. 

The  immobility  of  the  ribs  is  a  pathognomonic  sign  of  the  affec- 
tion and  the  involving  of  other  joints  would  merely  confirm  one's 
opinion  of  the  character  of  the  affection. 

The  early  stages  of  the  affection  have  never  been  seen  by  the 
writers  and  have  not  been  satisfactorily  described. 

It  need  hardly  be  said  that  the  prognosis  is  unfavorable.  The 
harm  done  is  irremediable  and  the  prospect  of  checking  the  general 
disease  almost  hopeless.  The  dorsal  curvature  will  probably  in- 
crease, and  if  the  other  joints  are  involved,  the  patient's  condition 
is  deplorable. 

Treatment. — In  the  matter  of  treatment  very  little  can  be  said. 
The  general  measures  useful  in  rheumatoid  arthritis  ordinarily 
should  be  faithfully  tried.  The  outlook  in  this  affection  is  no  bet- 
ter than  in  the  other  manifestations  of  these  diseases. 

Electricity  to  the  spine  may  be  of  some  use  in  altering  the  con- 
ditions of  the  local  circulation.  It  is  useless  to  try  to  ward  off  the 
approaching  ankylosis  by  manipulation  and  the  measure  is  harm- 
ful and  painful. 

Hot  application  and  hot  baths  sometimes  mitigate  the  symptoms. 

When  pain  is  present  on  motion,  mechanical  support  is  indicated. 

In  a  case  under  the  care  of  the  writer  excessive  pain  was  caused  by 

the  jar   of  walking  and  by  any  sudden  movement,  although  the 

spine  was  anchylosed  except  in  the  cervical  region.     A  steel  antero- 

13 


194 


ORTHOPEDIC  SURGERY. 


posterior  head  support  with  a  chin  rest  was  appHed,  and  the 
patient  obtained  relief  from  its  use,  and  a  decided  irritabihty 
of  the  cervical  muscles  was  quieted  and  he  was  able  to  move 
his  head  more  freely  than  before.  The  use  of  the  apparatus  in 
this  case  was  a  pure  experiment,  but  it  justified  the  hope  that 
some  relief  may  be  afforded  to  the  painful  cases  of  this  unfortunate 
class.  After  wearing  the  brace  for  some  months,  the  patient  was 
able  to  discontinue  its  use  gradually,  without  any  return  of  the 
pain. 

An  acuter  form  of  rheumatic  inflammation  of  the  vertebral  artic- 
ulations has  been  mentioned,  but  such  a  form  must  be  rare. 

Lordosis. 

Lordosis  of  the  spine,  with  the  convexity  forward,  is,  like  kypho- 
sis, either  due  to  an  increase  of  the  normal  physiological  curve,  or 
to  the  pathological  states  already  described. 

In    caries  of  the    spine    a 


compensatory  lordosis  below 
the  carious  point  is  not  un- 
common. 

In  paralytic  conditions,  the 
attitude  is  often  the  result 
of  an  attempt  to  balance  the 
weight  of  the  upper  part  of 
the  body  without  bringing  a 
strain  upon  the  back  mus- 
cles; the  attitude  character- 
istic of  pregnant  women,  and 
large-bellied  persons,  the  so- 
called  "  attitude  of  the  alder- 
man." 

This  is  also  true  of  the  lor- 
dosis from  muscular  weak- 
ness. 

Lordosis  also  exists  in 
pregnant  women,  in  persons 
with  large  fatty  abdomens 
or  abdomens  distended  from 
any  cause,    such    as    ascites 

and  abdominal  tumors.     In  these  cases  it  is  merely  a  balancing  of 

weight  by  which  the  centre  of  gravity  is  brought  over  the  centre 

of  support. 

The  deformity  also  exists  as  a  result  of  professional  training  in 

professional   gymnasts,   especially    in   the   class   of  gymnasts    who- 


Fig.  2, 


Extreme  Lordosis. 


OTIU'lR   AJ'1'1<:CTH)NS   ()/'-    Tlll'l  S/'/NE. 


'95 


have  been  trained  as  backward  contfjrtionists  and  are  able  to  bend  the 
spine  backward  to  an  unusual  decree.  These  contortionists  habit- 
ually walk  with  a  naarked  degree  of  lordosis, 

A  compensatory  lordosis  is  seen  in  cases  of  congenital  dislocation 
of  the  hip,  and  when  contraction  of  the  hip  joint  in  a  flexed  posi- 
tion has  occurred,  as  the  result  of  hip  disease  or  for  any  other 
reason. 

Lordosis  is  also  present  in  many  cases  of  rickets  on  account  of 
the  rotation  of  the  pelvis  on  a  transverse  axis  as  described  in 
Chapter  XIX. 

Lordosis  will  also  be  seen  in  cases  of  infantile  paralysis,  pseudo- 
hypertrophic paralysis  and  muscular  debility,  when,  owing  to  the 
weakness  of  the  back  muscles,  the  erect  position  cannot  be  main- 
tained through  ordinary  muscular,  tension  alone.  In  these  cases 
the  back  is  hollowed  out,  so  that  the  body 
weight  falls  further  back  and  the  muscles 
which  keep  the  spine  from  bending  are  not 
needed;  a  ligamentous  support  being  sub- 
stituted for  a  muscular  one. 

A  very  common  cause  of  lumbar  lordosis 
is  found  in  hip  disease,  whenever  by  muscu- 
lar rigidity  or  by  adhesions  the  leg  is  flexed     ^ 
upon  the  pelvis.     In  order  to   enable  that 
leg  to  be  put  on  the    ground,  the   lumbar 
region   bends,  allowing  the  pelvis  to  rotate 
and   the   flexed  leg  to  come  into  the  same 
plane  as  the  other.     In  this  way  the  patient  Fig.  249.— Appliance  for  Lordosis. 
is  able  to  stand  or  lie  with  the  legs  in  the  same  plane.     As  recov- 
ery from  hip  disease  with  a  leg  slightly  flexed  is  not  uncommon 
nor  an  altogether  undesirable  position  for  the  leg,  if  ankylosis  must 
be  present,  this  form  of  lordosis  is  one  which  is  commonly  met. 

For  the  same  reason  when  the  hip  is  flexed  for  any  other  reason, 
as  by  the  contractions  following  infantile  paralysis,  lumbar  lordosis 
is  equally  common. 

In  the  gymnastic  treatment  of  lordosis,  the  exercises  mentioned 
for  the  strengthening  the  muscles  of  the  back  in  lateral  curvature 
will  be  of  use. 

In  certain  cases,  supports  may  be  of  assistance.  Either  the  form 
of  corset  used  for  lateral  curvature,  or  an  appliance  which  presses 
on  the  sacrum  below  [e),  and  shoulders  above  and  exerts  counter- 
pressure  upon  the  abdomen  by  means  of  a  belt  band  (d)  secured  to 
the  back  uprights  (a  and  b). 


196  ORTHOPEDIC  SURGERY. 


Weak  Spines. 

A  class  of  spinal  troubles  due  to  strain  of  position  is  not  infre- 
quently met.     It  can  be  considered  under  two  heads: 

(i)  It  is  seen  in  patients  young  enough  to  go  to  school,  where 
the  routine  is  injurious  to  them,  and  where  cure  is  to  be  effected 
by  a  proper  division  of  study  and  recreation,  including  muscular 
exercise,  good  food,  and  fresh  air. 

(2)'  Those  who  have  drawn  from  their  stock  of  muscular  or  nerve 
force  in  the  development  of  their  intellect.  After  freedom  from 
the  restraint  of  school,  their  time  is  devoted  to  a  sedentary  life  or 
to  one  of  undue  nervous  excitement.  In  such  cases  the  great  mus- 
cles of  the  back  are  those  most  called  upon,  and  give  out  either 
from  want  of  nutrition  or  excessive  tension.  The  equilibrium 
which  is  maintained  by  concerted  action  of  the  muscles  of  each 
side  is  lost,  and  neuralgic  pains  and  backache  follow.  In  several 
cases  the  writers  have  noticed  a  slight  impairment  of  the  faradic 
contractility  of  the  muscles  on  the  convex  or  weaker  side. 

In  these  cases  the  attitude  is  usually  that  of  an  increase  of  the 
physiological  curves,  slight  kyphosis  and  lordosis  and  also  often  a 
lateral  curvature.  The  spinal  column  is  flexible  and  there  is  often 
local  hypersesthesia. 

The  daily  use  of  the  faradic  current  is  advisable.  Cold  sponging, 
friction,  massage,  light  gymnastic  exercises,  and  the  application  of 
a  light  support  made  of  cardboard,  wet  and  moulded  to  the  back, 
and  secured  by  a  bandage,  and  worn  at  times,  are  to  be  included 
in  the  treatment.' 

Spondylolisthesis. 

This  is  an  unc®mmon  affection,  sometimes  confounded  with  caries 
of  the  spine.  It  is  characterized  by  a  great  increase  of  the  forward 
curvature  of  the  spinal  column  in  the  lumbar  region. 

Franz  Neugebauer,^  in  a  most  excellent  paper  upon  the  subject, 
arrives  at  the  following  conclusions : 

That  the  deformity  is  not  so  rare  as  has  been  supposed. 

That  it  may  and  does  occur  in  both  sexes,  and  is  not  confined 
to  any  particular  age. 

That  it  is  an  acquired  deformity,  occurring  in  extra-uterine  life, 
without  the  concurrence  of  a  primary  dyscrasia  or  inflammatory 
disease  of  the  bones  (rhachitis,  osteomalacia,  caries,  ostitis). 

^  Keating-,  Philadelphia  Medical  Times,  February  26th,  1881. 
=  Archiv  filr  Gynaekologie,  Bd.  xix.,  xx. 


OTHER   AFFECTIONS   ()/■'    TJ/E  S/'/NE.  197 

That  althoLich  it  may  occur  in  those  early  subjected  to  the 
carrying  of  heavy  weights,  and  in  women  exposed  to  early  and 
frequent  pregnancies,  yet  in  the  majority  of  cases  it  has  a  distinct 
traumatic  origin,  and  is  to  be  looked  upon  as  a  surgical  deformity. 

Schroeder'  has  reported  nine  cases  which  are  discussed  from  an 
obstetrical  standpoint. 

Rokitansky"  has  described  two  cases. 

Gibney^  recently  reported  a  case  of  a  man  of  twenty-nine  years 
of  age,  previously  healthy,  who  was  thrown  from  a  horse-car,  strik- 
ing upon  his  back.  Several  ribs  were  fractured,  as  were  also  sev- 
eral of  the  spinous  processes  of  the  vertebrae,  and  there  was  a 
luxation  forward  of  the  lower  lumbar  vertebra  upon  the  sacrum. 
Unsuccessful  attempts  were  made  to  reduce  this  dislocation. 

The  chief  feature  in  these  cases, consists  in  the  separation  of  the 
body  of  the  last  lumbar  from  the  first  sacral  vertebra,  and  the  con- 
sequent sinking  of  the  lumbar  spine  into  the  pelvis,  so  that  the  in- 
ferior surface  of  the  last  lumbar  rests  on  the  anterior  surface  of  the 
first  sacral  vertebra.  The  anterior  surface  of  the  last  lumbar  ver- 
tebra is  directed  downward;  the  surfaces  of  the  fourth,  third,  and 
second  lumbar  vertebrae  form  an  arch,  the  most  prominent  part  of 
which  being  nearest  to  the  symphysis,  takes  the  place  of  the  normal 
promontory.  The  result  of  this  displacement  is  a  considerable  short- 
ening of  the  antero-posterior  diameter  of  the  inlet  of  the  pelvis. 

The  gradual  sinking  of  the  vertebrae  is  accompanied  by  an  atro- 
phy of  the  intervertebral  cartilages  and  by  a  bony  union  between 
the  lumbar  and  sacral  vertebrae.  The  weight  of  the  body  con- 
ducted through  the  spine  is  now  transmitted  to  the  anterior  surface 
of  the  sacrum  instead  of  to  its  base,  which  tends  to  throw  the 
pelvic  centre  of  gravity  forward.  This  is  compensated  for  invaria- 
bly by  lessened  inclination  of  the  pelvis,  the  anterior  portion  being 
slightly  tilted  upward.  The  backward  pressure  upon  the  base  of 
the  sacrum  forces  the  posterior  iliac  spines  wide  apart,  while  the 
apex  of  the  sacrum  is  thrown  forward,  thus  encroaching  on  the 
antero-posterior  diameter  of  the  outlet. 

Since  Kilian,  in  1853,  first  drew  the  attention  of  obstetricians  to 
the  spondylolisthetic  pelvis  through  the  specimen  known  as  the 
Prague  pelvis,  no  new  light  had  been  thrown  on  the  condition  until 
Neugebauer  in  1884  propounded  his  views  in  the  Aiuialcs  dc  Gy- 
ndcologie.  Until  then,  the  views  of  Rokitansky  and  Kilian  that  the 
lesion  originated  in  caries  of  the  vertebrae  were  generally  accepted, 


'  "  Lehrbuch  der  Geburtshiilfe,"  S.  576. 

^  "  Nouv.  Dictionaire  de  Medecine  et  de  Chirurgie  Prat.,"  vol.  xii. ,  p.  132. 

3  New  York  Med.  Record,  March  30th,  1879,  p.  347. 


198  ORTHOPEDIC  SURGERY. 

some,  however,  holding  that  the  deformity  was  due  to  rickets, 
osteomalacia,  tuberculosis,  or  hydrorrhachis. 

There  .are  seventeen  specimens  of  this  deformity  known  to  exist 
in  museums  and  elsewhere,  and  Neugebauer  concludes  from  an  ex- 
amination of  ten  of  these  that  spondylolisthesis  may  exist : 

(i)  On  the  ground  of  congenital  lateral  defect  in  the  ossification 
of  one  or  both  sides  of  the  arch  of  the  fifth  lumbar  vertebra,  espe- 
cially in  the  interarticular  portion  of  the  arch  (spondyloschizis  inter- 
articularis  congenita,  arcus  vertebralis). 

(2)  On  the  ground  of  a  primary  fracture : 

{a)  Of  the  sacral  articular  processes,  if  the  posterior  transverse 
span  of  the  arch  of  the  fifth  lumbar  vertebra  is  displaced  forward, 
and  its  inferior  articular  process  exhibits  a  corresponding  antero- 
posterior elongation, 

{b)  Of  the  interarticular  portion  of  the  arch  of  the  fifth  lumbar 
vertebra,  if  the  posterior  transverse  span  of  the  arch  is  not  dis- 
placed forward,  but  has  remained  in  its  normal  position,  and 
whether  the  lumbo-sacral  joint  is  ankylosed  or  not. 

Etiology. — The  primary  cause  of  this  deformity  is  a  separation  of 
the  articular  surfaces  of  the  last  lumbar  from  the  first  sacral  verte- 
bra, which  may  be  brought  about  by  fracture  of  the  transverse 
processes;  caries  of  the  transverse  processes  induced  by  trau- 
matism, or  by.  traction  upon  the  articular  ligaments  sufficient  to 
produce  luxation  (as  from  the  too  early  carrying  of  heavy  weights). 
Several  cases  due  to  the  latter  cause  have  been  reported  by 
Arbuthnot  Lane, 

Diagnosis. — Aside  from  the  recession  of  the  lumbar  spines,  one 
notes  a  prominence  of  the  same  with  widening  of  the  iliac  bones. 

Breisky '  calls  attention  to  the  peculiar  figure  of  persons  with 
spondylolisthetic  pelvis.  The  thorax  and  extremities  are  normal, 
while  the  abdomen  is  unusually  short  and  appears  to  have  sunk 
between  the  prominent  iliac  crests.  The  pelvic  inclination  is  les- 
sened, the  crests  of  the  ilia  are  wide  apart,  and  the  gluteal  region 
abnormally  steep. 

It  is  often  very  hard  to  distinguish  this  condition  from  caries  of 
the  spine,  and  at  times  the  diagnosis  is  impossible. 

Rickets  has  also  been  confounded  with  spondylolisthesis,  but  in 
any  case  where  the  rhachitic  changes  were  enough  to  cause  this 
same  prominent  lumbar  lordosis,  similar  rhachitic  changes  would  be 
present  in  other  parts  of  the  body. 

Prognosis. ^T\v&  prognosis,  of  course,  has  to  do  largely  with  the 
effect  of  such  a  deformity  upon  parturition. 

Treatment. — The  chief  importance  of  this  affection  is  in  its  effect 
'^  Breisky:  Archiv  f.  Gynaek. ,  Bd.  ix.,  1876,  p.  i. 


OTJ/KA'  .U'/'ECT/ONS   OF    nil':  S/'/N/C. 


199 


upon  jjarturition,   and    tliat  asjjcct    of   treatment    docs  not    belong 
here. 

The  reduction  of  the  dishjcation  might  be  attempted  in  recent 
cases  where  the  cause  was  clearly  traumatic,  but,  as  in  Gibney's 
case,  it  is  hkely  to  prove  unsuccessful.  In  general  it  may  be  said 
that  the  condition  is  irremediable. 

Malignant  Disease  of  the  Spine. 

This  condition  needs  little  more  than  mere  mention  in  this  con- 
nection. Sarcoma  and  carcinoma  of  the  vertebral  column  are  oc- 
casionally met,  and  in  their  origin  they  may  be  either  primary  in 
this  location  or  secondary  to  some  deposit  elsewhere. 

Sarcoma  is  often  primary,  and  in  several  reported  autopsies  has 
been  found  to  be  of  the  large-celled  type.  Michel '  has  described 
these  under  the  head  of  "tumor  myeloides."  Cysts  or  cavities, 
with  fluid  or  semi-fluid  contents,  are  frequently  found,  and  he  has 
suggested  a  relation  between  this  and  hydatid  cysts,  but  this  can 
hardly  be  sustained. 

Carcinoma  is  more  likely  to  be  secondary,  and  has  been  noted 
following  similar  disease  of  the  breast  and  testicle,  and  less  fre- 
quently of  the  liver  and  stomach.  The  occurrence  may  be  from 
direct  extension,  or  from  general  infection. 

The  disease  usually  begins  as  an  infiltration  of  the  spongy  tissue 
of  the  vertebral  bodies,  which  is  gradually  replaced  by  the  malig- 
nant growth.  There  may  be  but  little  change  in  the  appearance 
of  the  bodies,  but  these  will  be  found  converted  into  a  soft,  friable 
mass.  Destruction  of  the  bone  substance  with  deformity  may 
occur.  Small  growths  external  to  the  vertebrae  are  sometimes 
seen,  and  are  likely  to  be  mistaken  for  malignant  disease  of  the 
vertebral  column. 

The  disease  may  pursue  an  insidious  course,  and  not  be  suspected 
until  found  at  the  autopsy.  This,  however,  is  rare,  and  a  serious 
affection  is  usually  evident,  even  though  no  diagnosis  is  made. 
The  chief  symptoms  are  pain  and  paralysis,  and  both  are  the  result 
of  the  encroachment  of  the  growth  on  the  spinal  nerves  and  cord. 
Considering  the  course  of  the  former  and  the  intimate  relation  to 
the  diseased  bone,  it  is  not  surprising  that  pain  should  be  an  early 
and  prominent  symptom.  It  is  usually  increased  by  pressure  and 
motion.  The  location  of  the  pain  will  depend  on  the  site  of  the 
diseased  vertebrae,  and  will  be  accordingly  in  the  arms,  trunk,  or 
legs.  Edes""  states  this  symptom  may  disappear  more  or  less  com- 
pletely at  a  later  period.  The  paralysis  usually  follows  a  disturb- 
'"  Nouv.  Diet,  de  Med.  et  deChir.,"39,  222.     ^Edes,  Bost.  M.  S.  J.,  June  17th,  18S6,  559. 


200  ORTHOPEDIC  SURGERY. 

ance  in  sensation  and  is  due  to  compression  from  extension  of  the 
disease,  or  from  involvement  of  the  meninges.  It  may  be  partial 
or  complete,  as  a  rule  does  not  occur  suddenly,  and  may,  as  in  one 
case  reported  by  Edes,  show  the  result  of  the  extension  of  the 
pressure  to  different  parts  of  the  cord. 

The  occurrence  of  oedema  from  thrombosis  in  paralysis  rather 
favors  the  theory  of  this  disease  as  the  cause. 

Tenderness  over  the  spine  is  an  uncertain  sign,  and  probably  has 
no  more  diagnostic  importance  than  in  ordinary  spinal  caries. 
When  deformity  occurs  it  will  be  found  to  present  a  more  rounded 
prominence  than  is  usually  seen  in  Pott's  disease.  It  is  stated  that 
in  secondary  disease  the  course  is  more  rapid  than  in  primary. 

Hemorrhage  from  the  bowels  or  hematuria  has  been  observed  in 
several  cases. 

Charcot '  gave  the  name  of  "  paraplegia  dolorosa  "  to  the  condi- 
tion which  he  had  observed  to  follow  infiltration  of  the  vertebrae, 
more  particularly  those  cases  seen  by  him  after  cancer  of  the  breast, 
and  which  revealed  the  existence  of  this  disease,  which  was  other- 
wise latent.  These  symptoms  consist  of  pain,  chiefly  in  the  lumbar 
region,  and  radiating  through  the  lower  limbs..  In  character  these 
pains  are  lancinating.  There  is  formication,  sense  of  constriction 
about  waist,  no  anaesthesia,  but  on  the  other  hand  there  is  frequently 
hyperaesthesia.  Walking  is  usually  interfered  with,  but  complete 
paralysis  does  not  occur.  The  bladder  and  rectum  are  not  affected, 
and  there  is  no  marked  vaso-motor  disturbance,  as  shown  by  the 
tendency  to  rapid  formation  of  bedsores,  etc. 

When  following  malignant  disease  elsewhere,  which  can  be  rec- 
ognized, the  diagnosis  should  present  no  special  difficulty,  but  in 
other  instances  is  usually  hard  or  even  impossible.  It  should  be 
distinguished  from  aneurism  of  the  aorta,  and  cervical  pachymen- 
ingitis and  Pott's  disease. 

The  prognosis  needs  no  comment,  a  fatal  end  is  only  a  matter  of 
time. 

Distortion  of  the  Thorax. 

A  distorted  condition  of  the  thorax  presents  itself  either  as  a 
congenital  affection  or  as  a  result  of  pathological  change  in  bone. 
A  partial  absence  of  the  sternum  has  been  reported  in  a  small  num- 
ber of  cases  and  is  interesting  chiefly  as  a  freak  of  nature. 

The  prominence  of  the  sternum  results  in  a  certain  number  of 
rhachitic  cases  and  is  secondary  to  the  flattening  of  the  back  which 
by  elevating  the  ribs  makes  the  sternum  more  prominent. 

'  Charcot.  Comptes  rendus  de  la  Soc.  de  Biol.,  1865,  28. 


OTHF.R   AFFECTIONS   OF    77/ F  S/'/NF.  2OI 

Where  this  is  accompanied  by  a  sinking  in  of  ihr.  ribs  near  the 
junction  with  the  sternum,  the  deformity  popuhirly  known  as 
"chicken  breast"  (pectus  carinatum)  follows.  A  sinking  in  of  the 
lower  part  of  the  sternum  accompanied  by  the  [projection  of  the 
lower  part  of  the  ribs  is  also  to  be  observed  and  a  deep  hollow  at 
the  end  of  the  sternum  will  be  seen  which,  if  accompanied  by  large 
pectoral  development,  presents  a  deformity  whicii  may  be  alarming 
in  appearance  but  without  pathological  significance.  A  widening 
at  the  lower  part  of  the  chest  and  a  prominence  of  the  lower  rih)s 
in  front,  as  if  pressed  outward  by  a  distended  abdomen,  is  some- 
times to  be  seen.  These  deformities  require  no  treatment.  Slight 
deformities  of  the  chest  acquircd-by  continued  obstruction  to  clear 
breathing  have  been  described  by  Dupuytren,  Robert,  Hooper,'  and 
others. 

Pigeon  Breast  Deformity. — This  name  has  been  given  to  a  pro- 
trusion of  the  sternum  and  cartilages  of  the  ribs.  The  antero-pos- 
terior  diameter  of  the  chest  is  enlarged.  This  distortion  is  more 
common  in  young  children  than  in  adults,  which  probably  indicates 
that  the  patients  often  out-grow  the  deformity.  The  origin  of  this 
distortion  is  not  known,  but  it  is  supposed  to  be  due  to  an  imper- 
fect expansion  of  the  lungs  from  some  obstruction  occurring  at  a 
time  in  childhood  when  the  bones  were  soft  and  flexible. 

Dupuytren  has  stated  that  patients  with  this  deformity  have 
previously  suffered  from  enlarged  tonsils. 

This  is  also  the  opinion  of  Mr.  Timothy  Holmes. 

Certain  cases  of  dorsal  Pott's  disease  are  characterized  by  much 
deformity  of  the  chest  due  to  the  sinking  forward  of  the  upper 
dorsal  part  of  the  spine,  carrying  with  it  the  ribs.  They  have  been 
discussed  in  Chapter  I. 

^  "  Boston  City  Hospital  Reports,"  fourth  series,  66. 


CHAPTER   IV. 
THE   PATHOLOGY   OF   CHRONIC   JOINT   DISEASE. 

I.  Diseases  Affecting  the  Synovial  Membrane  ;  Anatomy  of  Synovial  Mem- 
branes ;  Chronic  Serous  Synovitis ;  Chronic  Purulent  Synovitis. — II. 
Joint  Diseases  Affecting  the  Cartilage ;  Hypertrophy  and  Atrophy ;  Pri- 
mary Inflammation  of  Cartilage ;  Secondary  Inflammation  of  Cartilage  ; 
Loose  Bodies  in  the  Joints. — III.  Joint  Diseases  beginning  in  bone ;  Tu- 
berculous Ostitis ;  Gummatous  Ostitis ;  Formative  Ostitis  (Arthritis  De- 
formans);  Exostoses;  Tumors  of  the  Joints;  Miscellaneous  Minor 
Affections  of  the  Bone. — IV.  Joint  Diseases  beginning  in  the  Periarticular 
Structures;  Ligamentous  Affections;  Periarticular  Abscess;  Bursitis — 
other  Affections  Impairing  Joints. 

The  pathology  of  chronic  joint  disease  is  a  very  extensive  sub- 
ject, the  Hterature  of  which  is  very  extensive,  especially  in  this 
transition  period.  For  no  part  of  the  pathological  domain  has  ex- 
perienced greater  or  more  radical  changes  in  the  last  few  years, 
and  to-day  one  has  no  accepted  classification  and  no  definite  path- 
ological system;  a  great  deal  has  been  written,  but  it  has  yet  to 
be  crystallized  into  some  definite  scheme. 

No  attempt  will  be  made  here  to  treat  exhaustively  the  very  ex- 
tensive subject  of  the  pathology  of  chronic  joint  disease ;  but  sim- 
ply to  present  it  in  its  practical,  surgical  aspect,  and  in  its  very 
important  clinical  relations.  The  pathology  of  chronic  joint  dis- 
ease can  be  best  considered  under  the  following  simple  headings: 

I.  Diseases  affecting  the  synovial  membrane. 

II.  Diseases  affecting  the  cartilage. 

III.  Diseases  affecting  the  bone. 

IV.  Diseases  affecting  primarily  the  periarticular  structures. 
The  consideration  of  acute  joint  disease  will  not  be  undertaken, 

as  it  cannot,  by  any  construction,  be  considered  as  coming  into  the 
domain  of  orthopedic  surgery. 

I.  Diseases  of  the  Synovial  Membrane.— \t  may  be  best  to  review 
very  briefly  the  construction  and  function  of  synovial  mem- 
brane before  considering  the  diseases  of  that  structure. 

Synovial  membranes  approach  so  closely  to  the  serous  mem- 
branes that  they  are  often  classified  with  them.  But,  although 
structurally  much  the  same,  they  differ  from  the  serous  membranes 


Tin:  PATJIOLOCV  Ol'    (.7/A'()N/C  Jo/N'f   I  >  IS  EASE.  ^         203 

ill  sccrctini,^  a  peculiar  fluid,  synovia,  and  tlicy  arc  not,  like  the 
peritoneum,  etc.,  closed  sacs,  in  all  joints  wliere  motion  takes 
place  (diarthrodia)  a  lubricatinij  fluid  is  necessary,  and  tliis  fluid 
is  furnished  by  the  so-called  syn(jvial  membrane.  Every  diarthrodial 
joint  is  lined  with  a  layer  of  synovial  membrane,  excej^t  in  the 
places  where  the  articular  cartilages  arc  in  contact.  Here  there  is 
no  membrane,'  except  at  tlie  edL,^^;  of  the  cartilages,  which  the  syn- 
ovial membrane  may  overlap  for  two  or  three  millimetres,-  before 
merging  into  the  cartilaginous  structure.  Fasciculi,  and  folds  of 
the  capsule,  the  internal  ligaments,  and  fatty  internal  protrusions 
are  all  covered  by  the  membrane. 

Synovial  membrane  is  thin  and  elastic.  Externally  it  merges 
into  the  tissue  of  the  joint-capsule,  while  its  inner  surface  is  smooth 
and  moist.  Histologically  the  structure  is  a  basement  tissue  of 
elastic  and  connective-tissue  fibres,  upon  the  inner  surface  of  which 
lies  a  single  layer  of  endothelial  cells  (His).  In  gross  the  inner 
surface  of  a  joint  presents  a  smooth  and  shining  surface,  inter- 
rupted, especially  where  the  membrane  folds  to  pass  from  one  sur- 
face to  another,  by  the  synovial  fringes  (plicae  synovialesj — villous 
structures  of  varying  size  and  length,  somewhat  resembling  intes- 
tinal villi,  the  largest  being  perhaps  one  centimetre  long.  They  are 
richly  supplied  with  blood-vessels,  for  each  villus  contains  the  con- 
voluted twig  of  an  artery.  Some  of  the  fringes,  however,  are 
merely  hernia-like  protrusions  into  the  joint  of  small  masses  of  fat, 
covered  by  membrane;  these  fill  up  unoccupied  spaces.  The 
nerves  are  derived  from  the  same  nerve-trunks  that  supply  the 
muscles  of  the  limb.  The  nerve-filaments  terminate  in  small  plex- 
uses, unequally  distributed,  under  the  synovial  membrane.  The 
lymphatic  network  is  not  easily  demonstrated,  but  that  it  exists  is 
evident  from  the  fact  that  coloring  matter  injected  into  the  joint 
disappears  very  quickly,  to  reappear  in  the  lymphatic  channels  of 
the  limb. 

Synovia  is  a  clear,  alkaline  fluid,  much  like  the  white  of  &^^  in 
general  appearance;  when  rubbed  between  the  fingers  it  imparts 
an  oily  sensation.  It  is  largely  secreted  by  the  cells  which  cover 
the  synovial  fringes.  In  structure  it  contains  albumin,  mucin, 
some  fat,  leucocytes,  and  epithelial  cells.  A  fluid  identical  in  com- 
position with  synovia  can  be  produced  by  rubbing  up  a  portion  of 
the  epidermis  in  a  weak  alkaline  solution.  This  fact  suggests  ^  that 
most  of  the  mucin  is  derived  from  the  endothelial  cells  soaking  in 
the  weak   alkaline   fluid   secreted   by  the   fringes,  and   this  view  is 

^  Cornil  and  Ranvier  :  "  Path.  Hist.,"  227.     Philadelphia,  iSSo. 
=  Cadiat  et  Robin  :  "  Diet.  Encyc.  des  Sc.  Med.,"  ix. ,  3,  549. 
^  Barwell  :    "  Diseases  of  the  Joints,"  p.  22.     London,  1S81. 


204 


ORTHOPEDIC  SURGERY. 


strengthened  by  the  fact,  discovered  by  Frerichs,'  that,  when  joints 
are  quiet,  the  synovia  in  them  contains  only  half  as  much  mucin  as 
when  they  are  in  motion. 

Chronic  inflammations  of  the  synovial  membrane  begin  as  such, 
or  they  represent  the  continuance  of  an  acute  synovitis  affecting 
the  joint.  In  general  these  inflammations  are  characterized  by  an 
increased  secretion  or  perversion  of  synovia  and  a  structural  change 
in  the  membrane  which  often  goes  on  so  far  that  it  invades  other 
structures,  and  the  cartilage  and  bone  become  secondarily  affected. 

Chronic  synovitis  appears  under  one  of  two  heads:  chronic 
serous  synovitis  or  chronic  purulent  synovitis,  according  to  the 
character  which  the  synovial  fluid  assumes. 

Chronic  serous  synovitis  is  also  known  by  the  names  of  dropsy 
of  the  joint,  hydrarthros,  hydrarthrosis,  hydrops  articulorum  chron- 
icus,  etc.  As  a  rule,  pathological  changes  are  present  in  the  syn- 
ovial membrane  of  a  character  about  to  be  described;  but  certain 
cases  show  no  pathological  changes  beyond  this  increase  of  fluid 
for  a  long  time,  and  these  are  the  cases  which  have  given  rise  to 
the  names  hydrops,  hydrarthron,  etc.  These  cases  were  at  first 
thought  to  be  dropsical,  and  non-inflammatory,  like  hydrocele  ;  but, 
such  a  view  is  maintained  at  present  by  few.  On  the  other  hand 
we  have  Blandin,-  Bonnet,^  Billroth,-*  Volkmann,^  Cornil  and  Ran- 
vier,^  and  Marsh,  who  place  it  among  inflammatory  affections. 

It  must  be  said,  however,  that  the  fluid  in  the  joints  resembles 
the  fluid  of  hydrocele  in  color  and  consistency;  but  it  contains 
mucus,  which  is  not  the  case  in  hydrocele,  and  as  compared  with 
the  fluid  of  simple  dropsy  it  contains  more  albumin.  As  opposed 
to  the  view  that  this  is  a  dropsical  affection  it  may  be  said  that 
femoral  aneurism  and  other  obstructions  to  the  leg  circulation  do 
not  cause  joint  distention  even  in  extreme  oedema,  and  even  in  the 
cases  of  primary  hydrops  articulorum  (which  are  not  so  common 
as  those  where  it  is  secondary  to  acute  affections)  the  view  is  now 
held  that  it  is  an  inflammation  of  low  grade,  with  slight  tissue 
change. 

The  most  common  form  of  chronic  serous  synovitis  is  where  it 
succeeds  one  attack  or  a  series  of  attacks  of  acute  synovitis,  and 
here  the  pathological  changes  are  evident,  although  they  are  at  first 
very  slight.  One  sees  in  the  commencement  only  a  slight  increase 
of  vascularity  and  a  tendency  to  thickening  of  the  membrane  which 
begins,  perhaps,  to  look  boggy  from  soaking  in  the  excess  of  joint 

^  Frerichs  :   Wagner,  "  Handworterbuch  der  Phys. ,"  iii.,  i,  446. 

^  "  Diet,  de  Med.  et  de  Chir.  pratique,"  8,  89. 

3  Bonnet:  "  Mai.  des  Artie."     Paris,   1845.  •*  Arch.  f.  kl.  Ch.,  ii.,  408. 

*  Billroth:   "  Surg.  Path.,"  1883,  Am.  ed.,  p.  578.     *  Cornil  and  Ranvier's  "  Plistology." 


THE  J'ATHOLOGV  OF   CHA'ON/C  JO/NT  DISEASE.  205 

fluid.  This  fluid  may  be  insij^niificant,  or  very  lar^Uj  in  amount;  it 
is  ordinarily  yellowish  or  colorless,  but  at  times  it  is  red  from  blood 
originally  effused. 

Increased  vascularity  and  thickening  of  the  membrane  arc  fol- 
lowed by  an  hypertrophy  of  the  synovial  fringes,  described  above. 
This  hypertrophy  varies  from  a  slight  and  almost  imperceptible 
hyperplasia  to  a  condition  where  the  fringes  are  transformed  into 
a  mass  of  fibrous  polyj)i,  so  that  the  synovial  surface  may  be  fairly 
shaggy.  At  other  times  they  are  translucent,  seeming  to  be  (as 
they  often  are)  fat  globules  '"nclosed  in  a  delicate  capsule. 

Meantime,  the  subsynovial  tissue  has  hypertrophied,  and  in  some 
cases  it  is  known  to  have  increased  to  an  inch  in  thickness,  and  if 
the  fluid  has  been  long  in  the  joint  the  synovial  membrane  and  the 
parts  below  it  look  light  yellow,  pulpy,  and  boggy.  If  the  effusion 
has  been  extreme  the  capsule  has  either  become  enormously  thick- 
ened or  has  given  way  and  become  much  distended.  If  so,  the 
lateral  and  internal  ligaments,  weakened  by  the  continual  tension 
and  soaked  by  the  contained  fluid,  have  also  stretched,  and  lateral 
motion  may  be  found  in  the  knee-joint,  even  to  the  extent  of  60"". 

There  may,  however,  have  been,  instead,  a  development  of  cysts 
in  connection  with  the  joint,  practically  herniae.  These  occur 
oftenest  in  the  popliteal  space  in  connection  with  the  knee-joint 
(Baker ') . 

The  synovial  membrane  in  certain  cases  begins  to  encroa  upon 
the  cartilage.  Normally,  it  runs  into  the  cartilaginous  border  for 
two  to  three  millimetres,  but  now  the  hypertrophied  membrane 
sends  out  processes  which  creep  in  still  further,  as  pannus  does  on 
the  cornea.  These  cases  Hueter  calls  syiiovitis  Jiyperplastica pan- 
nosa.  It  is  simply  an  extension  of  the  process  that  we  have  con- 
sidered above.  It  may  go  on  to  the  formation  of  granulation  tis- 
sue, but  it  is  not  likely  that  it  will.  Purulent  cases  generally  follow 
another  type,  as  will  be  seen,  and  after  changes  in  the  synovial 
membrane  have  reached  this  grade,  secondary  changes  in  the  car- 
tilage are  likely  to  begin.  These  are  fatty  degeneration  of  the  car- 
tilage cells,  fibrillation  of  the  hyaline  substance,  and  consequent 
disorganization  of  the  structure.  If  it  falls  away  and  leaves  the 
ends  of  the  bones  bare,  eburnation  and  enlargement  of  the  ends  of 
the  bones  results.  The  outcome  of  simple  serous  synovitis  is  in 
absorption  or  suppuration,  or  a  persistence  of  the  condition  with  a 
continually  increasing  disability  of  the  joint.. 

The  Jiydrops  articiiloru)>i  tJibcrculosus  of  Konig  is  a  peculiar  form 
of  serous  synovitis  that  must  be  mentioned.  This  is  a  primary 
tuberculosis  of  the  synovial    membrane,  and   Konig  accounts  for 

'  St.  Barth.  Reports,  xiii. 


2o6  ORTHOPEDIC  SURGERY. 

its  existence  by  the  supposition  that  the  irritation  caused  by  the 
tubercules'  growth  is  not  enough  to  produce  its  ordinary  man- 
ifestation, in  fungous  granulations.  It  occurs  most  often  in  a  dif- 
fuse tuberculosis  of  the  synovial  membrane ;  sometimes  in  that 
form  of  chronic  synovial  inflammation  characterized  by  the  enor- 
mous connective-tissue  formation  described  above;  the  class  of 
cases  which  Hueter  calls  synovitis  hyperplastica  tuberosa;'  and 
thirdly,  in  some  cases  of  fungous  synovitis  in  children,  to  be  de- 
scribed later.  The  effusion  has  more  of  a  serous  than  of  a  purulent 
character.  The  tubercles  may  be  found  present  in  a  synovial 
membrane  almost  unchanged  by  inflammation  where  there  were 
no  symptoms  of  note  before  death.  Ordinarily,  however,  the  mem- 
brane is  thickened  and  succulent,  and  studded  with  tubercles  even 
into  the  subsynovial  tissue.  The  surfaces  tend  toward  granula- 
tions; if  these  are  fully  developed  t>he  effusion  is  generally  purulent 
rather  than  watery.  The  exudation  is  often  fibrinous,  so  that 
coagulation  products  of  many  shapes  are  present  in  the  form  of 
loose  bodies,  like  melon-seeds,  rice,  etc. ;  and,  although  formerly  it 
was  held  that  such  bodies  did  not  occur  in  tuberculous  affections, 
Konig  and  Riedel""  now  consider  that  the  finding  of  these  loose 
bodies  in  the  hydrops  of  a  joint  or  a  tendon,  increases  the  likeli- 
hood that  the  affection  is  tuberculous.  This  tuberculosis  of  the 
synovial  membrane  ordinarily  coexists  with  a  tuberculosis  of  the 
neighboring  bone,  although  there  is  no  communication  between  the 
two,  and,  from  their  appearance,  neither  is  secondary  to  the  other. ^ 

There  is,  finally,  a  form  of  chronic  serous  synovitis  where  the 
effusion  is  so  scanty  that  the  affection  goes  by  the  name  of  dry 
synovitis,  or  arthrite  plastique  ankylosante.  At  times  this  appears 
as  an  acute  affection ;  but  again,  and  perhaps  more  often,  it  is 
found  as  a  distinctly  chronic  joint  disease  generally  in  connection 
with  some  infectious  cause,  such  as  gonorrhoea.  The  effusion  is  so 
small  as  to  be  imperceptible,  but  it  is  so  rich  in  fibrin  that  the 
ends  of  the  bones  are  fairly  soldered  together  directly  by  the 
organized  exudation,  although  the  changes  in  the  cartilage  are 
slight. •* 

Chronic p7ir7ilent  synovitis  is  also  called  in  English,  white  swelling,, 
fungous  joint  disease,  gelatinous  arthritis,  pulpy  degeneration  of 
synovial  membrane,  strumous  arthritis,  etc. 

In  German,  Fungose  Gelenkentziindung,  Die  granulirend  tuber- 
culose  Gelenkentziindung  and  Gliedschwamm  ;  in  French,  Tumeur 

'  Bohm,  R. :  "  Beitrage  zur  Norm,  and  Path.  Anat.  der  Gelenke,"    Wurzburg,  1868-69.. 

^  Riedel :    Deutsche  Z.  f.  Chir.,  Bd.  x. 

3  Konig:    "  Die  Tuberc.  der  Knochen  und  Gelenke,"  S.  22.     Berlin,  1884. 

^  Gaz.  des  Hop.    Jan.  23d,  1881. 


THE   I'AT1I()IA)(}Y  Dh'    CI  I  Ni)N  IC  J( )/ XT   J  )/S/':,IS /■:.  207 

fongucusc,  and  tlic  Latin  names  of  the  affection  are  Synovitis 
hyperplastica  fungosa  (Hucter),  I'yartiirosis,  lilmpyeina  articuloruni, 
and  last  and  most  widely  known  of  all,  Tumor  albus.  The  name 
tumor  albus  was  originally  given  by  Wisemann  to  practically  all 
classes  of  chronic  joint-disease  characteri/x-d  by  swelling,  and 
Brodie  was  the  first  to  restrict  its  application  to  that  class  called 
by  him  "  pulpy  degeneration  of  the  synovial  membrane."  Since 
that  time  it  has  stood  as  the  name  for  tliat  pathological  con- 
dition, being  especially  applied  to  the  knee-joint,  until  of  late 
years  the  terms  strumous  and  tuberculous  have  come  to  be  applied 
to  it. 

Like  chronic  serous  synovitis,  chronic  purulent  synovitis  is  either 
the  continuance  of  an  acute  affection  or  it  begins  as  a  chronic  dis- 
ease, insidiously  and  perhaps  without  assignable  cause.  At  other 
times,  however,  it  is  the  result  of  chronic  serous  synovitis  when 
that  terminates  in  suppuration. 

The  first  stage  in  chronic  purulent  synovitis,  when  it  begins  as 
such,  is  an  increase  of  vascularity  in  the  synovial  membrane  and 
perhaps  an  extension  of  it  on  to  the  cartilage.  The  synovial  fluid 
is  increased  in  amount  and  the  peri-articular  tissues  are  more  or 
less  infiltrated  with  serum. 

From  this  stage  the  membrane  becoiries  velvety,  the  cartilages 
look  yellowish,  and  the  synovia  has  been  replaced  by  a  fluid,  vary- 
ing from  turbid  serum  to  laudable  pus.  It  is  possible  to  say  in 
advance  what  a  continuation  of  this  condition  would  lead  to,  and 
the  later  changes  found  in  chronic  purulent  synovitis  represent 
this  continuance. 

The  hypertrophied  and  infiltrated  synovial  membrane  takes  on 
still  greater  activity;  cell  formation  and  vascular  supply  become 
very  much  increased,  and  the  result  is  a  typical  but  rather  low- 
grade  granulation  tissue,  Avhich  is  yellowish  or  pinkish,  and  admir- 
ably described  by  the  terms  pulpy  and  gelatinous.  Microscopically 
it  does  not  difTer  in  any  way  from  granulation  tissue  as  found  else- 
where, except  that  it  often  contains  in  its  structure  small  white 
specks,  which  are  visible  to  the  naked  eye,  and  which  are  the  struc- 
tures described  by  Koster  {Virch.  Archiv,  Bd.  48)  as  tubercles. 
They  were  almost  constantly  found  by  him  embedded  in  this  tissue 
around  the  edge  of  the  joint,  and  later  in  the  disease  generally 
through  the  fungous  tissue.  The  proof  of  the  identity  of  the  struc- 
tures is  well  enough  established ;  Koster  considered  them  true 
miliary  tubercles  {Arch,  dc  PJiys.,  1870,  p.  325),  Brissaud  {Rev. 
Mens,  tie  Med.  et  de  Chi?'.,  June  loth,  1879")  thought  that  although 
joint  fungus  undoubtedly  occurred  without  the  occurrence  of 
tubercles,  there  is  abundant  microscopic  proof  that  tubercle  is  the 


2o8  ORTHOPEDIC  SURGERY. 

chief  element.  In  this  view,  that  the  structures  found  are  true 
tubercles,  Konig  {Deutsch.  Arch.  f.  Chir.,  1879,  XL,  317  and  350), 
Friedlander,  and  Ranke  agree.  Bacilli  are  found  in  a  certain  pro- 
portion of  caSes,  as  will  be  seen  later. 

When  the  granulations  are  fully  developed  they  secrete  of  course 
a  purulent  fluid,  and  they  may  melt  into  pus  very  rapidly  or  very 
slowly,  and  in  certain  parts  of  the  joint  the  process  may  be  much 
more  advanced  than  in  other  parts. 

But  this  stage  of  disease  in  the  synovial  membrane  will  not  have 
been  reached  without  accompanying  changes  in  the  cartilage  and 
bone.  The  cartilage  becomes  yellow  and  loses  its  opalescence,  and 
if  one  tries  to  lift  from  it  the  synovial  hypertrophies  where  they 
have  grown  over  on  to  it,  they  often  cling  to  it,  and  if  they  are 
pulled  away  leave  a  red  and  eroded  surface  of  cartilage  under 
them.  The  cartilage  may,  however,  become  granular  first  in  other 
places,  especially  where  the  opposing  surfaces  are  in  contact,  and 
notably  does  this  occur  when  the  limb  is  in  malposition  and  parts 
of  the  cartilage  not  altogether  used  to  it  become  roughly  pressed 
together  by  the  tonic  muscular  contraction.  Often  the  whole  de- 
generated cartilage  may  be  detached  and  cast  off  from  the  bone,  or 
it  may  be  disintegrated  in  flakes.  When,  by  the  disintegration  of 
the  protecting  cartilage,  the  granulations  reach  the  bone  they  at- 
tack the  tissue  of  the  epiphysis  in  all  directions. 

Hypersemia  of  the  ends  of  the  bones  has  already  been  present 
for  some  time,  accompanying  the  joint  inflammation,  and  the  bone 
structure  is  readily  destroyed  by  the  action  of  the  granulations. 
There  is  now  no  limit  to  be  set  to  the  destructive  processes;  the 
ends  of  the  bones,  softened  and  embedded  in  a  mass  of  jelly,  are 
crowded  against  each  other  by  the  muscular  contraction,  and  a 
sinus  is  probably  draining  off  the  products  of  the  destruction. 
The  ligaments,  infiltrated,  degenerated,  and  over-stretched,  have 
given  way,  and  dislocations,  complete  or  partial,  have  probably 
already  occurred,  generally  as  a  result  of  the  predominance  of  the 
flexor  muscles  over  the  extensors.  The  formation  of  intra-articular 
abscesses  and  their  escape  to  the  surface  through  the  degenerated, 
capsule  needs  no  explanation  ;  a  fistulous  track,  lined  with  the  same 
gelatinous  material,  marks  their  path.  Sometimes  the  abscess  has 
been  extra-articular  and  results  from  the  breaking  down  of  the 
periarticular  cellular  infiltration,  which  contributes  so  much  to  the 
enlargement  of  the  joint. 

On  the  other  hand  at  any  period  of  the  affection  reparative  pro- 
cesses may  set  in.  The  granulation  tissue  then  becomes  less  suc- 
culent; the  areolar  tissue  in  it  more  prominent,  and  the  cells  less 
numerous;    in  time  fibrous  tissue  forms  in  its  place  and  from  this 


THE  J' ATM O LOGY  OF   CHRONIC  JOINT  DISEASE.         209 

may  result  complete  or  [);irti;il  ankylosis;  if  these  fibrous  bands 
become  ossified  so-called  true  ankylosis  is  the  result,  if  the  car- 
tilages have  not  been  extensively  destroyed,  or  if  the  affection  has 
been  chiefly  synovial,  any  degree  of  restoration,  even  complete 
mobility,  may  result. 

It  is  not  uncommon  to  find  associated  with  fungous  joint  disease, 
tuberculosis  of  the  lungs,  of  the  meninges,  or  general  miliary 
tuberculosis.  ' 

The  division  of  the  affection  into  stages  has  no  justifiable  patho- 
logical bass. 

II.  Joint  Diseases  Affecting  the  Cartilage. — Such  affections  are 
known  by  the  name  of  chrondritis,  ulceration  of  cartilage,  degen- 
.'iration  or  fibrillation  of  cartilage,  etc. 

Cartilage  is  a  tissue  of  low  grade,  non-vascular  and  sluggish  in 
all  its  reactions,  and  it  is  to  this  that  we  must  turn  for  the  explan- 
ation of  the  extreme  rarity  of  primary  inflammatory  disease  of 
the  cartilages  of  the  joints.  Surrounded  on  one  side  by  synovial 
membrane  and  on  the  other  by  bone,  this  tissue  lies  in  the  neigh- 
borhood of  far  more  irritable  tissues  than  itself  which  react  to  any 
trauma  or  constitutional  irritant  long  before  the  cartilage  does. 

Hyaline  cartilage  is  a  bluish-white,  opalescent  structure  of  great 
density,  which  covers  the  ends  of  the  bones  in  all  diarthrodial 
joints.  It  is  non-vascular  and  derives  its  nutriment  from  the  bone 
and  synovial  membrane,  which  furnishes  another  explanation  why 
secondary  affections  are  so  common.  It  consists  of  hyaline  sub- 
stance and  corpuscles  which  lie  embedded  in  it  and  contain  one  or 
more  nuclei.  These  corpuscles  lie  near  the  joint-surface  in  layers 
parallel  to  it,  but  deeper,  near  the  bone,  in  columns  perpendicular 
to  the  cartilaginous  surface,  which  accounts  for  the  readiness  Avhich 
the  cartilage  shows  to  be  chipped  vertically.  Externally  the  carti- 
lage is  attached  to  the  bone  by  the  perichondrium,  and  the  internal 
sui-face  lies  free  and  moist  in  the  joint. 

Fibro-cartilage,  when  present,  appears  as  a  cross  between  fibrous 
and  cartilaginous  tissue.  It  appears  in  three  forms — intra-articular ; 
circumferential,  as  around  the  acetabulum  ;  and,  lastly,  as  the  con- 
necting substance  in  joints  which  do  not  move  (amphiarthroses\  as 
in  the  symphysis  pubis.  Histologically  it  consists  of  fibrous  tissue 
intermixed  with  cartilage-cells  and  it  possesses  far  greater  tough- 
ness and  elasticity  than  hyaline  cartilage. 

Hypertrophy  and  atrophy  of  the  joint  cartilages  are  pathological 
processes  occasionally  alluded  to,  the  former  is  seen  in  the  margi- 
nal ecchondroses '  of  arthritis  deformans,  and  in  children  where 
ossification  has  been  delayed  the  articular  cartilages  may  appear  to 

'  Cornil  and  Ranvier:   "  Path.  Hist.,"  Phila.,  iSSo.  p.  236. 
14 


2IO  ORTHOPEDIC  SURGERY. 

be  very  thick.  Atrophy'  of  the  cartilages  occurs  to  a  very  sHght 
extent  in  the  joints  of  old  people,  and  sometimes  where  joints  are 
subjected  to  very  great  pressure-  decided  atrophy  of  the  cartilage 
(as  of  all  the  articular  structures)  takes  place.^ 

The  degenerative  changes  in  cartilage  follow  a  type  which  is 
peculiarly  constant.  The  phases  are  many,  but  the  process  is  es- 
sentially the  same.  It  is,  in  a  word,  a  cell  multiplication,  and  fatty 
or  granular  degeneration  of  the  corpuscles  with  a  fibrillation  of  the 
hyaline  substance.  Whether  we  have  in  question  primary  or  sec- 
ondary inflammation,  the  results  of  injury,  or  the  degeneration  of 
gout,  it  will  be  seen  that  the  cartilage  in  its  behavior  follows  very 
closely  the  type  of  degeneration  described  above. 

Primary  inflammation  of  cartilage  is  a  rare  disease,  and  in  the 
great  majority  of  so-called  cases  the  affection  of  the  cartilage  is 
secondary.  In  fact  the  existence  of  primary  disease  is  denied  by 
such  men  as  Hiiter,  Barwell,  etc.,  but  there  have  been  recorded 
from  time  to  time  certain  cases  which  seem  to  establish  the  fact 
that  primary  erosion  of  the  cartilage  does  occur. 

The  writer  in  Holmes'  "Surgery"  says:  "Inflammatory  ulcera- 
tions of  the  cartilages,  unaccompanied  by  disease  of  any  other 
joint-tissue,  x^-A.y  possibly  take  place,  though  cases  of  it  are  not  easily 
met  with  ;  "  and  that  seems  a  fair  statement  of  the  situation.  Years 
ago  the  discussion  was  not  as  to  primary  disease,  but  as  to  whether 
inflammation  was  present  in  cartilage  at  all,  and  whether  the 
changes  found  were  not  the  result  of  the  other  tissues  acting  on  it. 
The  researches  of  Redfern,"  Goodsir,^  Virchow,  and  Weber*  estab- 
lish the  active  character  of  the  changes  well  enough,  and  give  the 
story  of  the  controversy.  As  to  the  existence  of  primary  disease, 
Brodie'  reported  some  cases  that  he  considered  primary  cartilage 
disease ;  but,  looked  at  in  the  light  of  modern  pathology,  there 
seems  but  little  doubt  that  they  were  cases  of  primary  disease  of 
bone.  The  same  is  true  of  a  case  called  "  acute  idiopathic  ulcera- 
tion of  cartilage  "  reported  by  Mack,®  where  the  bone  "  was  exten- 
sively carious."  Panas'  claims  to  have  found  erosion  and  ulcera- 
tion of  cartilage  without  disease  of  other  tissues.  Bauer  reported 
a  case  in  1871,  where  there  seemed  little  doubt  that  it  was  a  case 

'  Barwell:  "  Dis.  of  Joints,"  p.  408. 

^  Holmes'  "  Syst.  of  Surg.,"  vol.  iii.,  p.  55. 

3  Arbuthnot  Lane:  St.  Barth.  Hosp.  Reports. 

t  Redfern:  Month.  J.  Med.  Sci. 

5  "  Anatomical  and  Pathological  Researches,"  Edinburgh,  1845. 

*  Weber:  Virch.  Archiv,  1878. 

■*  Brodie,  Benj. :  Quoted  in  Holmes'  "  Surgical  Diseases  of  Children." 

®  Buffalo  Medical  and  Surgical  Journal,  1850,  v.,  385. 

5  Article,  Articulations,  "  Nouv.  Diet,  encyc.  de  Med.  et  Chir. "     Paris. 


THE  J'A'niOLOifV  ()/■'   CHRONIC  JOINT  iJ/SIiASIC.  211 

of  primary  cartihic^inous  disease  of  tlic  intervertebral  discs,  and  at 
autopsy  the  eight  upper  dorsal  discs  had  been  destroyed,  while  the 
cervical  discs  had  become  soft  and  pulpy.  The  patient  was  fifteen 
years  of  age,  and  the  disease  had  lasted  six  years;  there  was  prob- 
ably a  traumatic  origin.  Other  cases  of  suppurative  inflammation 
of  the  intervertebral  discs  are  recorded  by  Ogle,"  Broca,-=  and  Chas- 
saignac,^  where  ulcerative  changes  were  found  in  one  or  more  of 
the  intervertebral  discs,  which  varied  from  a  small  perforation  to 
complete  disappearance  of  the  disc. 

Kocher  ■*  reports  three  cases  of  circumscribed  fungous  disease  of 
the  internal  meniscus  in  the  knee-joint.  • 

Secondary  I nflavDiiation  of  Cai'tilagc. — As  a  result  of  the  inflam- 
mation of  synovial  membrane  or  bone,  secondary  inflammation  of 
cartilage  is  very  common.  The  number  of  nuclei  in  the  cells,  and 
the  number  of  cells  in  the  corpuscles,  multiply  very  fast.  There  is 
a  certain  amount  of  fatty  degeneration  of  the  cells  present,  and 
striation  of  the  hyaline  substance  goes  on  to  fibrillation,  and  local 
or  general  disintegration  of  that.  The  cells  break  from  the  cor- 
puscles and  infiltrate  the  whole  cartilage;  it  becomes  yellowish 
and  soft.  If  the  process  is  very  acute  the  hyaline  substance  is 
disintegrated  without  having  time  to  undergo  much  fibrillary  de- 
generation and  the  production  of  leucocytes  is  the  prominent  part 
of  the  process.  If  it  is  slower,  fibrillation  is  more  marked.  At 
any  rate,  disintegration  generally  comes  on,  and  where  the  carti- 
lage is  gone  (generally  where  the  pressure  is  greatest)  an  ulcer  with 
a  granulating  base  and  clean-cut  edges  is  seen,  of  greater  or  less 
extent.  The  base  of  the  ulcer  consists  of  typical  granulation- 
tissue,  and  in  this  way  the  entire  cartilage  may  quickly  disappear, 
or  these  ulcers  may  go  on  to  cicatrization  and  heal  by  the  forma- 
tion of  a  connective-tissue  scar. 

At  times  when  ostitis  is  the  cause  of  the  secondary  inflammation 
of  the  cartilage  the  inflammation  of  the  bone  may  have  cut  off 
the  nourishment  supply  of  the  cartilage,  and  it  undergoes  necrosis 
and  is  cast  off  into  the  joint,  where  the  yellow  opaque  pieces  lie 
loose,  or  are  disintegrated  into  pus. 

What  is  known  as  the  "  fatty  degeneration  of  cartilage  "  is  merely 
the  regular  degeneration  of  cartilage,  and  when  the  fibrillation  is 
slow  and  fatty  degeneration  of  the  cells  predominates  it  does  not 
cause  ulcers,  but  the  degenerated  fibres  are  tough  and  resistant 
and  attached  at  one  end  and  they  lie  with  the  other  free  in  the 
joint-cavity.     Intermingled  with  the  fibres  are  fat-globules  and  a 

'  Path.  Soc.  Trans.,  xv.,  1863,  p.  i,  and  vol.  iv.  of  same,  1S53,  p.  27. 
-  Gaz.  Hebdom.,  1864,  p.  29S.  3  Gaz.  des  Hop.,  1S5S,  p.  156. 

■•  Cent.  f.  Chir. ,  November  5th,  i83i. 


212  ORTHOPEDIC  SURGERY. 

few  leucocytes  and  the  cartilage-corpuscles  are  either  disintegrated 
or  filled  with  fat-globules.  The  fibres  may  wear  away  and  leave 
the  bare  ends  of  the  bone,  not  ulcerated  and  covered  with  pulpy 
granulations,  but  white  and  eburnated.  Fatty  degeneration  of  car- 
tilage is  considered  to  be  analogous  to  the  arcus  senilis  of  the 
cornea  in  its  etiology  and  pathology. 

In  other  cases  the  process  is  known  by  the  name  of  the  "  fibril- 
lary degeneration  of  cartilage."  Fatty  degeneration  and  cell-multi- 
plication in  the  cartilage-corpuscles  assume  a  subordinate  place, 
and  fibrillation  of  the  hyaline  substances  becomes  the  all-impor- 
tant part  of  ihe  degeneration.  The  fibres  are  well-marked,  and 
where  pressure  occurs  they  are  worn  away,  evenly  or  unevenly. 

Where  they  are  worn  away  again  we  see  white  bone  thickened 
and  ivory-like;  and  calcareous  degeneration  occurs  in  the  patches 
of  the  degenerated  cartilage.  It  is  "the  ossification  of  cartilage." 
Around  the  edges  the  cartilage  is  covered  by  the  synovial  mem- 
brane, probably  hypertrophied,  and  here  cell-formation  and  fibril- 
lation begin  as  well  as  elsewhere ;  but  the  cells  cannot  escape, 
having  no  free  cartilaginous  surface,  and  they  are  retained  and 
become  active  in  the  form.ation  of  cartilage,  and  the  marginal 
ecchondroses  of  which  we  have  spoken  are  formed,  so  Marsh  '  says. 
In  time  calcareous  deposits  occur  in  these  as  well.  Sometimes  they 
break  off,  and  form  one  kind  of  the  "  loose  bodies  "  in  the  joint. 

The  deposition  of  urate  of  soda  in  the  hyaline  substance  may, 
perhaps,  be  called  the  gouty  degeneration.  It  is  not  a  different 
process  from  the  others — cell-multiplication  and  fibrillation  go  on 
as  before.  This  urate  deposit  is  simply  superadded  in  the  cartilage, 
where  it  is  sometimes  seen  (in  very  acute  cases)  as  a  simple  superfi- 
cial layer,  then  later,  in  white  patches  which  are  larger  below  the 
surface,  where  on  more  careful  examination  it  is  seen  to  have  left 
the  corpuscles  free  and  to  have  settled  in  the  hyaline  substance 
around  them.  Still  later  it  also  invades  them,  and  disintegration 
goes  on.  A  simultaneous  deposit  of  urate  of  soda  occurs  in  liga- 
ments, bones,  and  the  periarticular  structures. 

Loose  bodies  in  the  joints  come  in  for  consideration  more  aptly 
under  the  diseases  of  cartilage  than  they  do  elsewhere.  The  other 
names  for  the  condition  are,  loose  cartilages,  joint  mice,  floating  or 
movable  bodies  in  joints,  mures  articulorum,  corpora  libera  artic- 
ulorum,  etc.  They  can  be  divided  into  three  classes,  according  to 
their  structure,  as  follows: 

{a)  Fibromatous,  {b)  Lipomatous,  (<:)  Chondromatous. 

These  bodies  lie  free  in  the  joint  or  attached  by  a  slender  pedicle. 

They  vary  in  size  from  a  small  pea  to  a  horse-chestnut  or  larger, 
'Marsh:   "  Diseases  of  Joints." 


THE  PATll()U)i}Y  OF   CHRONIC  JOJN'r  /J/S/wUS/C,  213 

and  are  of  all  shapes.  .The  smaller  ones  are  most  often  shaped  like 
melon-seeds,  or  irregularly  round,  while  tlie  larger  ones  are  more 
regularly  round,  concavo-convex,  or  spherical.  Sometimes  they 
are  facetted  and  crowded  together  like  the  carpal  bones,  and  then 
again  they  are  mulberry-shaped  or  pyriform.  In  (me  joint  they 
may  appear  singly  or  in  great  numbers,  and  they  may  vary  a  great 
deal  in  size  in  the  same  joint.  Mr.  T.  Smith  removed  recently  over 
four  hundred  from  one  knee-joint.'  The  knee-joint  is  by  far  the 
most  apt  to  be  affected,  and  Harwell  estimates  that  nine-tenths  of 
all  cases  occur  in  that  joint.-  Next  in  frequency  comes  the  elbow,' 
and  all  of  the  larger  joints  are  liable  to  contain  these  bodies.  In 
external  appearance  they  are  whitish  or  yellowish,  and  vary  from  a 
soft  consistency  to  a  bony  hardness.  On  section  they  show  either 
a  plain  fibrous  structure,  or  a  fibrous  sheath  inclosing  a  mass  of  fat. 
Again,  the  structure  is  of  hyaline  or  fibro-cartilage,  ordinarily  with- 
out corpuscles,  or  of  bone  tissue,  most  often  without  Haversian 
canals.  Frequently  they  present  a  combination  of  two  of  these 
forms. 

They  are  often  found  in  connection  with  the  changes  known  as 
arthritis  deformans,  and  also  in  the  form  of  chronic  synovitis, 
already  alluded  to  as  synovitis  hyperplastica  tuberosa,  where  the 
.synovial  fringes  become  much  hypertrophied ;  sometimes  these 
hypertrophies  are  pedunculated,  and  if  the  stalk  breaks  the  syno- 
vial tuft  is  left  free  in  the  joint  as  a  loose  body. 

Again,  they  originate  in  severed  enchrondromata  or  osteophytes 
which  have  grown  into  the  joint  and  been  broken  off;  and  some- 
times cartilaginous  or  bony  plates  develop  in  the  synovial  fringes 
or  the  joint  capsule  and  are  separated  and  lie  loose  in  the  joint.  At 
other  times  the  free  body  seems  to  be  only  the  remains  of  a  blood 
clot  from  a  preceding  acute  synovitis  or  the  consolidated  residue  of 
an  effusion  very  rich  in  fibrin. 

Lastly,  there  is  certainly  a  class  of  traumatic  cases  Avhicli  have 
been  much  discussed.  Formerly  it  was  held  that  these  free  bodies 
(of  the  chondromatous  class)  were  the  result  of  the  direct  forcible 
tearing  off  of  pieces  of  cartilage  by  wrenches  or  strains  or  blows, 
and  Hiiter  supports  that  view*  as  does  also  Virchow.^  The  more 
modern  view  is  represented  by  Konig,  who  does  not  deny  the  pos- 
sibility of  this  tearing  off  of  bits  of  cartilage,  but  he  insists  upon 
its  rarity  and  shows  the  great  force  necessary  to  detach  them  in 

'  Howard  Marsh:  "  Diseases  of  Joints,"  p.  1S3. 
=  Harwell :  "  Diseases  of  Joints,"  p.  26S.     London,  iSSi. 
3  Konig  :  Arch.  f.  klin.  Chir.,  1SS8. 

4  Cf.  Erodhurst:    St.    George's  Hospital   Reports,    1S67,   ii.   s,,  141-144,  and   Volk- 
mann:  Deutsche  Klinik,  1867.  No.  48. 

s  "  Die  Krankhaften  Geschwi'ilste,"  p.  450.      Berlin,  1S63. 


214  ORTHOPEDIC  SURGERY. 

this  way.  Rather,  he  says,  consider  that  theSe  pieces  are  so  bruised 
and  injured  by  the  trauma  that  their  necrosis  follows,  and  then  a 
spontaneous  osteochondritis  desiccans  takes  place  which  leads  to 
their  detachment  and  sets  them  free  in  the  joint.  Cases  in  which 
the  traumatic  origin  of  these  chondromatous  free  bodies  is  beyond 
question,  are  given  by  Mr.  Marsh; '  notably  one  where,  three  weeks 
after  a  wrench  to  the  knee,  a  free  body  was  removed  by  Mr.  Simon, 
which  Mr.  Shattock  pronounced  to  be  a  piece  of  the  articular  sur- 
face.^ • 

There  seems  reason  to  believe  that  in  spite  of  the  lack  of  blood- 
vessels these  bodies  are  nourished,  after  being  set  free  in  the  joint ; 
not  only  does  ossification  of  them  take  place  after  they  are  freed, 
but  the  case  of  Recklinghausen  ^  would  seem  to  show  that  growth 
is  also  possible. 

III.  Joint  Diseases  Beginning  in  Bone.  —The  chief  chronic  disease 
of  bone  which  ultimately  involves  the  joints  as  well,  is  a  patholog- 
ical process  which  is  distinctly  a  degenerative  ostitis;  a  certain 
amount  of  formative  activity  accompanies  the  process;  but  the 
general  type  is  distinctly  degenerative. 

In  general  terms  the  process  is  as  follows:  there  is  a  hyperaemia 
of  the  vessels  and  infiltration  from  the  distended  capillaries  and 
consequent  absorption  of  the  trabeculae,  which  leads  to  the  forma- 
tion of  the  enlarged  spaces  known  as  the  lacunae  of  Howship.  The 
bone  cells  degenerate  into  fat  and  are  finally  replaced  by  embry- 
onic tissue,  and  when  this  stage  has  been  reached  of  course  the 
mechanism  is  at  hand  for  any  amount  of  destruction  of  bone  tissue. 

The  greater  part  of  degenerative  ostitis  of  the  ends  of  the  bones, 
especially  in  children,  whom  this  form  chiefly  affects,  follows  one 
distinct  type  which  is  to-day  classed  as  tubercular.  The  evidence 
which  supports  this  view  will  be  presented,  and,  in  advance  it  may 
be  said  that  this  evidence  is  of  such  a  character  that  it  lends  much 
support  to  the  view  that  this  chronic  degenerative  ostitis  is  really 
a  tubercular  affection. 

This  disease,  perhaps  most  correctly  known  as  tuberculous  osti- 
tis, is  identified  with  a  large  number  of  other  names.  In  English, 
scrofulous  joint  disease,  tuberculosis  of  joints,  chronic  articular 
ostitis  (of  which  most  cases  are  tubercular)  and  in  general  the  term 
of  "  caries  "  of  the  joints. 

German,  scrofulose  Caries,  tuberculose  Caries,  Knochen-Nekrose,. 
Knochen-Abscess,  scrofulose  Gelenkentziindung,  and  fungose  Ar- 
thritis. 

'  Howard  Marsh:  British  Medical  Journal,  April  14th,  1888. 

^  Pathological  Society  Transactions,  xv. ,  p.  206. 

3    '  De  Corp.  Liberis  Articulosum."     Regimonti,  1864. 


THE  r  ATI  10  LOG  V  01''   CHRONIC  JOINT   DlSICylSli. 


215 


Latin,  Caries  mollis  sivc  fungosa,  fungus  arliculi,  caries  sicca,  etc. 

French  names  aim  at  greater  precision  in  speaking  of  osteo-pd-ri- 
ostite  tuberculose  chroni(|ue  and  tubcrculose  articulaire,  not  to 
mention  such  fine  distinctions  as  tubercule  tardif  a  evolution  rapide' 
and  osteite  aigue. 

In  whatever  joint  it  appears  it  presents  itself  in  much  the  same 
form,  as  an  affection  of  the  spongy  tissue  of  the  epiphysis,  most 
often  near  its  line  of  junction  with  the  shaft;  but  sometimes  near 
the  articular  cartilage,  and  rarely  in  the  periosteum.  It  occurs 
mostly  as  a  localized  disease,  appearing  in  one  or  more  distinct  foci 
(encysted  tubercle  of  Nelaton);  a  simultaneous  tuberculous  infil- 
tration of  the  whole  epiphysis  (the  infiltrated  tubercle  of  Nelatonj, 
however,  rarely  happens. 


Fig.  250. — Juxta-epiphyseal  Ostitis  of  the  Hip. 


Fig.  251. — Abscess  of  the  Epiphysis. 


The  common  form  of  tubercular  infection  of  the  epiphyses  is  the 
one  spoken  of  as  focal  or  encysted,  where  the  first  change  is  the 
formation  of  single  or  multiple  foci  of  tubercular  degeneration. 
On  section  of  the  diseased  epiphysis  the  first  noticeable  change  con- 
sists in  a  local  hypersemia  of  some  part  of  the  spongy  tissue.  There 
then  appears  in  this  hyperaemic  area  a  small  grayish  translucent 
spot  almost  as  small  as  one  can  see,  which  grows  more  gray  and 
increases  in  size,  while  a  zone  of  hyperjemic  tissue  develops  around 
it  and  the  neighboring  bone  looks  boggy  from  an  excess  of  the 
transuded  fluid.  There  is  no  synovitis,  it  is  purely  a  localized 
ostitis. 

As  the  diseased  focus  grows  larger  it  looks  more  yellow  in  spots, 
and  shows  at  its  centre  a  tendency  to  cheesy  degeneration  and  later 
in   the  history  of  the  affection  one  finds  nodules,  varying  in  size 

'  Keiner  and  Poulet:   Arch,  de  Phvs.,  1SS3,  p.  224. 


2i6  ORTHOPEDIC  SURGERY. 

from  that  of  a  pea  to  a  hazelnut,  which  are  filled  with  a  putty-like 
substance,  such  as  the  cheesy  material  found  elsewhere  in  the  body, 
except  that  it  contains  spicules  of  bone  from  the  trabeculae,  and  in 
the  larger  foci  pieces  of  dead  bone  of  considerable  size  are  found. 

Later  in  the  history  of  the  affection  the  tuberculous  nodule 
breaks  down  into  pus,  and  it  is  said  that  at  this  stage  absorption 
has  occurred,  leaving  nothing  but  a  cavity  filled  with  limpid  serum.' 

Generally  the  original  focus  is  surrounded  by  smaller  tubercles 
which  aid  in  its  extension ;  but  the  chief  work  is  done,  as  we 
shall  see,  by  the  erosive  action  of  the  granulations  (rarefying  osti- 
tis). Sometimes  a  sequestrum  of  considerable  size  may  be  found  in 
these  cavities ;  the  granulations  have  cut  off  the  source  of  nourish- 
ment from  a  certain  area  of  bone,  and  it  has  died  and  is  loosened 
from  the  sounder  parts,  and  lies  loose  in  the  cheesy  or  liquid  pus; 
or  a  piece  of  bone  too  large  to  be  contained  in  the  cavity  may  die 
and  be  detached  as  a  wedge-shaped  piece  as  at  the  end  of  the  tibia. 
Usually  these  larger  pieces  are  of  a  wedge  shape,  with  the  base  at 
the.  end  of  the  bone,  the  ordinary  shape  of  an  infarction.  Even 
the  whole  epiphysis  of  the  femur  may  be  detached.  It  should  be 
noted  that  the  cavity  is  sometimes  sharply  marked  and  lined  by 
more  or  less  of  a  pyogenic  membrane,  which  at  first  is  soft  and 
gelatinous,  later  it  becomes  more  resistant  and  tougher. 

From  this  stage  of  the  process  any  one  of  three  courses  is  possi- 
ble:  the  diseased  focus  may  be  absorbed  and  so  cured;  it  may 
extend  to  the  periphery  of  the  bone,  and  break  through  the  peri- 
osteum and  empty  itself  there  ;  or,  lastly,  and  probably  most  com- 
monly, it  may  extend  to  the  joint  and  infect  that. 

The  absorption  of  the  diseased  focus  is  theoretically  possible  up 
to  a  late  stage  in  the  process,  so  long  as  the  disease  remains  strictly 
local  and  no  sequestra  of  any  size  have  formed ;  the  pus  may  be- 
come cheesy  and  calcified,  or  less  frequently  it  may  be  absorbed  as 
mentioned  above,  leaving  a  cavity  filled  with  serum.  This  termin- 
ation, of  course,  is  one  which  only  comes  to  the  knowledge  of  the 
pathologist  accidentally,  and  so  it  is  accounted  very  rare. 

The  next  most  favorable  termination  to  the  disease  is  where  the 
focus  does  not  infect  the  joint  but  breaks  through  the  periosteum, 
and  discharges  into  the  peri-articular  structures.  This  happens 
when  the  focus  is  so  situated  that  the  line  of  least  resistance  takes 
it  to  another  part  of  the  bony  surface  away  from  the  joint.  Volk- 
mann  showed  clearly  that  this  was  no  very  uncommon  occurrence. 

As  it  reaches  the  periosteum  the  latter  thickens  and  inflames,  and 
finally  softening,  allows  the  pus  from  the  original  focus  to  pass  into 
the  peri-articular  structures,  there  to  form  an  abscess  which  must  be 
'  Vincent's  Article,  Ashhurst's  "  Encyclopaedia,"  vol.'vi.,  p.  908. 


THE  J'ATJ/OLOGV  UJ''   CJIRONJC  JOINT  DISJCASE.         217 

evacuated  externally  or  break.  Scjmetiines  this  ends  the  disease; 
the  granulation  tissue  becomes  fibrous,  and  then  osseous,  and  the 
disease  is  over. 

Probably  the  commonest  course  for  this  localized  ostitis  to  jjur- 
sue,  is  to  break  into  the  joint  cavity,  and  the  ease  with  which  in- 
fection of  the  joint  from  the  epiphysis  is  produced  will  be  readily 
understood  by  co'   .idering  the  pathological  conditions. 

The  seat  of  the  disease  in  the  beginning  is  ordinarily  not  far 
from  the  cartilage.  At  first  it  excites  no  joint  inflammation,  but 
when  it  reaches  a  certain  stage,  even  before  it  breaks  into  the 
joint,  inflammatory  reaction  in  the  joint  begins.  This  is  perfectly 
well  established.  Take  one  of  Lannelongue's  early  autopsies,'  e.g., 
in  a  case  of  early  hip  disease  a  focus  the  size  of  a  pea  was  found 
in  the  epiphysis  two  millimetres  from  the  cartilage;  it  was  caseous 
and  did  not  in  any  way  communicate  with  the  joint,  yet  although 
there  was  no  effusion  the  capsule  was  thickened,  the  synovial  mem- 
brane in  parts  reddened  and  fungous,  and  the  round  ligament 
already  vascular  and  softened.  The  cartilage  in  certain  parts  was 
thinner  and  losing  its  elasticity.  One  other  of  his  autopsies,  and 
the  early  resections  of  Volkmann-  show  the  same  point,  the  latter 
finding  even  more  advanced  joint  changes  than  Lannelongue's 
autopsies  showed,  for  increase  of  synovial  fluid,  swelling  of  peri- 
articular structures,  and  thick  and  red  synovial  membrane  were 
present,  before  the  pus  had  entered  the  joint. 

It  should  be  remembered  that  opportunities  to  study  the  early 
stages  of  joint  affections  are  very  rare,  but  it  would  seem  then  as 
if  often  the  joint  were  involved  and  inflamed  in  the  first  place  by 
contiguity  rather  than  direct  infection,  and  by  its  inflammation  and 
the  softening  of  cartilage  over  the  diseased  spot  of  bone  rendered 
the  more  ready  for  the  direct  invasion  of  the  pus  and  caseous 
material  from  the  primary  focus. 

"  The  danger  to  the  joint  begins  with  the  softening  of  the  cheesy 
masses  "  (Volkmann).  When  once  the  pus  has  broken  through  the 
softened  and  degenerated  cartilage  and  has  reached  the  synovial 
membrane,  a  purulent  synovitis  is  at  once  started  up  which  speedily 
assumes  a  fungous  and  destructive  character  and  a  "  panarthritis  " 
has  begun.  Thickening  of  the  capsule,  infiltratiofi  of  the  peri- 
articular tissues,  and  thickening  of  the  ends  of  the  bones  follow 
quickly,  and  abscess  formation  and  all  the  other  complications  are 
ready  to  follow.  It  matters  little  now  whether  the  process  began 
in  the  synovial  membrane  or  the  bone,  as  this  stage  is  the  same  in 
its  clinical  appearances  and  its  capability  for  evil.     Any  amount 

^  Lannelongue:  "Coxo-tuberculose,"  Paris,  1S86. 
^Volkmann:   "  Samml.  Klin.  Vortr.,"  No.  52. 


2i8  ORTHOPEDIC  SURGERY. 

of  destruction  is  of  course  easily  possible:  erosion  of  the  articular 
surfaces;  spontaneous  subluxations  and  luxations  of  the  joints; 
cold  abscesses  of  any  extent  reaching  the  surface  and  continuing 
to  discharge  by  many  sinuses  ;  and,  worst  of  all,  from  the  local  dis- 
ease the  dissemination  of  general  tuberculosis  or  tubercular  menin- 
gitis or  phthisis. 

Microscopical  examination  of  the  diseased  area  at  any  time  be- 
fore all  structure  is  lost  shows  a  typical  granulating  tuberculosis. 
Within  the  low-grade  granulation  tissue  one  finds  numerous  and 
characteristic  tubercles  with  epithelioid  and  giant  cells  (Konig)^ 
but  with  the  increase  of  cheesy  degeneration  the  typical  tuber- 
culous structure  becomes  more  and  more  obscure. 

The  tubercles  are  found  in  a  dense  plasma  composed  of  a  great 
quantity  of  amorphous  matter,  fatty  and  calcareous  granules  and 
leucocytes.  Outside  of  this  one  sees  enlarged  bone  spaces,  atrophy 
of  the  trabeculae,  and  fatty  degenerated  bone-cells,  becoming  embry- 
onic tissue  as  one  nears  the  seat  of  disease.  In  short  these  are  the 
changes  which  accompany  long-continued  hypersemia  in  bone  and 
constitute  the  rarefying  ostitis  of  French  writers. 

There  seems  little  doubt  that  the  original  infection  comes  most 
often  by  means  of  the  blood-vessels  (Konig,  Miiller,  Vincent,  Zieg- 
ler).  Sometimes,  probably,  the  lymph-channels  are  to  be  blamed, 
but  the  beginning  of  the  process  is,  in  general,  understood  to  be  of 
the  following  character,  although,  of  course,  it  is  partly  conjectural.'' 

Bacilli  or  micrococci  become  heaped  up  in  the  capillary  of  a 
Haversian  canal,  cut  off  the  blood-supply,  and  start  up  in  the 
neighborhood  an  endarteritis  of  the  type  known  as  tubercle,  an  in- 
filtration of  leucocytes,  the  formation  of  a  lacuna  of  Howship,  and 
the  formation  and  continual  increase  of  embryonal  or  granulation 
tissue.  The  trabeculae  grow  thin,  and  the  bone-cells  undergo  fatty 
degeneration  and  disintegrate,  while  their  place  is  taken  by  the 
embryonal  tissue-cells,  which  continually  extend  and  melt  away  the 
bone  substance.  Hence  the  formation  and  extension  of  the  dis= 
eased  focus.  Sometimes,  however,  the  seat  of  disease  is  surrounded 
by  a  condensing  rather  than  a  rarefying  ostitis.  Kiener  and  Poulet 
make  three  stages  of  the  process,  which,  perhaps,  will  explain  the 
sequence  a  little  more  fully:  (i)  fibrous  or  embryonal  transforma- 
tion of  the  marrow;  (2)  appearance  of  the  follicles  with  condensing 
and  rarefying  ostitis ;  (3)  caseation  of  the  marrow  and  eventual 
necrosis  of  the  trabeculae. 

'  Kiener  and  Poulet  (in  Arch,  de  Phys.,  1880)  have  demonstrated  that  the  cells  of  the 
inner  walls  of  the  capillaries  of  the  diseased  region  hypertrophy  and  undergo  hyaline  de- 
generation, form  a  giant  cell  which  fills  the  capillary  ;  the  other  coats  of  the  vessels  are 
infiltrated,  the  follicle  is  formed,  and  the  vessels  closed. 


77/ A"   rATIlOJJ)GY  OF   CI  I  RON  IC  JOI  NT   D/SJwlSf:.  219 

When  the  absorption  of  a  tuberculous  ff)cus  takes  place,  the  spot 
of  diseased  tissue  becomes  cheesy  and  the  granulation-wall  sur- 
rounding it  changes  from  its  erosive  to  a  formative  action,  having 
a  tendency  to  send  processes  into  the  cheesy  mass,  which  processes 
become  fibrous  and  ultimately  bony  tissue,  but  the  tendency  is 
to  incomplete  scarring,  a  bit  of  tuberculosis  granulation  remains 
behind,  perhaps  for  years,  and  explaining  in  a  measure  the  ten- 
dency to  later  relapses  in  this  class  of  disease.  The  entire  absorp- 
tion of  large  sequestra  is  very  doubtful  (Konig). 

Primarily  or  secondarily,  the  periosteum  is  quite  sure  to  be  af- 
fected. If  primarily,  a  tuberculous  focus  is  seen  under  the  peri- 
osteum and  the  bone  destruction  around  it  is  superficial,  it  is  "  eine 
periphere  Caries ;  "  but  if  the  periosteal 
focus  is  secondary,  it  communicates 
with  the  original  point  of  disease  in  the 
marrow.  The  periosteal  foci,  like  the 
others,  become  cheesy  or  melt  down 
to  form  abscesses.  But  even  before 
the  tubercular  focus  is  deposited  in 
the  periosteum,  increased  periosteal 
activity  begins ;  sometimes  with  absorp- 
tion of  the  deposited  inner  layers,  as  in 
spina  ventosa,  where  the  whole  circum- 
ference increases,  yet  the  marrow  cav- 
ity increases  more  all  the  time  ;  while 
in  other  cases  osteosclerosis  (a  forma- 
tive ostitis)  takes  up  the  whole  bone.  F.g.  252.-Diffuse  Epiphyseal  Ostitis. 

The  second  and  rare  form  of  tuberculous  inflammation  may  be 
considered  very  briefly.  When  simultaneous  infiltration  of  a  whole 
epiphysis  occurs  it  is  characterized  by  the  deposit  in  the  meshes  of 
the  spongy  tissue  of  a  gray  substance  like  brain  tissue,  Avhich  is  in 
gross  appearance  like  the  focal  lesion  just  mentioned,  without  limit 
or  boundary.  Yellowish  pus  collections  are  to  be  seen  in  spots, 
which  ultimately  extend,  and  the  whole  affair  soon  assumes  the 
aspect  of  a  true  purulent  osteomyelitis,  and  it  is  this  stage  that  is 
ordinarily  found  on  section.  The  true  tuberculous  infiltration 
presents  a  different  appearance  from  the  subsequent  puriform  in- 
filtration, which  is  characterized  by  a  dull  yellow  surface  and  an 
absence  of  blood-vessels. 

Having  considered  the  pathological  appearances  in  this  so-called 
tubercular  form  of  joint  disease  it  now  becomes  necessary  to  inves- 
tigate wifh  care  the  evidence  presented  in  favor  of  considering  it  a 
tuberculous  affection. 

Microscopic  examination  shows  a  typical  granulating  tuberculo- 


220  ORTHOPEDIC  SURGERY. 

sis.  Even  in  the  cases  where  large  seq-uestra  form  in  the  ends  of 
the  bones  without  any  evident  tuberculous  foci,  one  can  ordinarily 
find,  without  trouble,  tubercles  in  the  granulation  layer  between 
the  sequestrum  and  sound  bone. 

With  Koch's  discovery  of  the  bacillus  of  tubercle  in  1882,  there 
came  in  a  new  criterion  in  the  determination  of  whether  or  no  cer-. 
tain  microscopical  appearances  really  represented  tuberculosis.  By 
improved  methods  the  presence  or  absence  of  bacilli  can  be  deter- 
mined by  a  simple  microscopical  examination.  They  are  most 
often  found  lying  in  the  giant  cells,  and  sometimes  in  the  other 
cells  ;  they  are  few  in  number,  and  hard  to  find.  Koch  '  discovered 
them  in  two  cases  out  of  four  in  fungous  joint  disease.  Since  then 
various  observers  have  found  them  in  varying  proportion  of  all 
cases  examined.  Schuchardt  and  Krause  investigated  all  cases  of 
"  fungous  and  scrofulous  joint  disease  "  coming  to  Volkmann's  clinic 
for  some  weeks,  some  forty  cases  altogether,  in  all  of  which  they 
found  the  bacilli  of  tuberculosis;  but  they  were  very  few  in  num- 
ber, and  very  hard  to  find.  A  modification  of  Ehrlich's  method 
was  used.  In  one  cold  abscess  twenty  sections  were  required  to 
find  two  bacilli.  Kanzler,^  in  15  cases  of  bones  and  joints  exam- 
ined, found  bacilli  in  only  8.  Miiller^  examined  some  39  cases, 
using  the  pus  for  the  most  part,  and  in  a  few  cases  he  was  unable  to 
find  the  bacilli,  although  he  would  examine  most  carefully  perhaps 
twenty  preparations.  He  believes,  on  the  strength  of  this,  that  it 
is  possible  to  have  tuberculous  joint  disease  without  the  presence 
of  bacilli.  Castro  Sofifia,"*  in  a  great  number  of  clinical  cases  of  bone 
tuberculosis  examined  for  bacilli,  was  always  able  to  find  them.  Ros- 
well  Park  5  in  a  systematic  examination  of  detritus  and  pus  from  this 
class  of  cases  extending  over  a  period  of  two  years  was  able  to  find 
tubercle  bacilli  in  nearly  all  instances.  Reuben,*  in  five  cases  of  spina 
ventosa,  otherwise  free  from  tuberculous  disease,  found  the  bacilli 
in  all  cases,  looking  for  them  in  the  granulations,  and,  moreover, 
inoculation  was  successful.  In  general,  the  results  of  later  years  are 
more  positive  than  the  earlier  results,  probably  from  perfection  of 
methods.  The  evidence  presented  seems  to  justify  the  conclusion 
that  in  most  cases  of  chronic  joint  disease  of  the  character  just 
described,  tubercle  bacilli  are  present,  but  that  the  examination 
for  them  is  difficult;  and,  moreover,  that  they  are  present  in 
smaller   numbers  at  the  late  stage,  when  most  examinations  are 

^  Fortsch.  der  Med.,  1883,  9.  Bd.  i.,-  S.  277. 

^  Kanzler :  Berl.  klin.  Wochenschrift,  1884,  2,  Jan.  14th. 

3  Mtiller  :  Cent.  f.  Chir.,  1884,  p.  33. 

'■  These  de  Paris,  "  Recherches  exp.  sur  la  Tuberculose  des  Os,"  1885. 

s  Med.  Press  of  West  N.  Y.,  Jan.,  1887. 

^  Baumgarten's  "  Jahrbuch,"  1886,  ii.,  230. 


THE  PATHOLOGY  OJ''   Clfh'OjV/C  JO/A'T   D/SlwiSE.  221 

made;  probably  in  the  staf^c'of  invasion  examination  of  tlic  tissues 
would  show  many  more. 

Experimental  research  has  proved  tiiat  substances  containing  the 
bacilli  of  tuberculosis  are  capable  of  producing  tuberculosis  when 
introduced  into  the  general  circulation.  It  has  also  been  proved 
with  equal  certainty  that  substances  in  which  they  are  present,  if 
inoculated  into  animals,  under  proper  precautions,  will  produce 
local  and  general  tuberculosis,  as  is  also,  of  course,  true  with  regard 
to  pure  cultures  of  the  bacillus.  It  may  be  mentioned  in  passing 
that  it  matters  not  whether  the  tissue  for  inoculation  is  taken  from 
a  scrofulous  joint  or  a  phthisical  lung,  the  result  is  the  same — 
nothing  could  testify  more  strongly  than  this  in  favor  of  the  iden- 
tity of  tuberculosis  and  scrofula. 

The  importance  of  inoculation  experiments  in  establishing  the 
identity  of  this  form  of  joint  affection  is  very  great.  Arnold  in- 
serted into  the  anterior  chamber  of  a  rabbit's  eye  a  small  fragment 
from  a  scrofulous  joint  or  gland,  and  in  six  days  the  bacilli  of 
tubercle  were  present  in  great  numbers  in  the  corneal  tissue,  and 
soon  after  that,  young  tubercles  were  found.  In  about  five  weeks 
tubercles  could  be  demonstrated  in  the  kidneys,  and  general  tuber- 
culosis caused  the  death  of  the  animals.  The  same  results  were 
obtained  by  the  inoculation  of  pure  cultures.' 

Another  point  in  the  chain  of  evidence  is  to  demonstrate  the 
susceptibility  of  the  human  species  to  tubercular  inoculation. 
Lehmann-  relates  the  tubercular  infection  of  ten  children  (fatal  in 
seven)  who  were  circumcised  by  a  phthisical  rabbi  in  a  small  con- 
tinental town.  The  prepuce  became  the  seat  of  tubercular  ulcera- 
tion and  the  inguinal  glands  enlarged  and  suppurated.  Similar 
cases  are  related  by  Elsenberg,^  Mecklen,  and  Hoist, ■•  where  the 
presence  of  bacilli  in  the  affected  tissues  was  demonstrated. 

A  case  related  by  Pfeiffer  deserves  especial  mention.  A  veteri- 
nary surgeon  of  good  antecedents  and  in  sound  health  punctured 
the  joint  of  his  thumb  with  a  knife,  while  dissecting  a  tubercular 
cow,  a  synovitis  of  the  tubercular  type  followed  and  he  died  in  a 
year  and  a  half  of  phthisis.  His  thumb  joint  showed  typical  tuber- 
cular structures  in  which  bacilli  abounded. ^ 

With  the  understanding  of  these  facts  it  becomes  necessary  to 
consider  inoculation  experiments  as  they  bear  directly  upon  the 
question  of  joint  disease. 

'  Baumgarten:  Cent.  f.  d.  Med.  Wiss.,   1SS3  ;  Baumgarten  :  Zeit.  f.   Kl.   Med.,  Bd. 
9  and  10;  W.  Cheyne:  Practitioner,  1SS3. 

=>  Deutsch.  Med.  Woch.,  18S6,  9-13.  3  Cent.  f.  Chin,  18S7,  p.  52, 

^  Quoted  by  Barber:  Brit.  M.  J.,  June  23d,  18SS. 
«  Pfeiffer:  Fort,  der  Med.,  iSSS,  No.  i,  p.  33. 


222  ORTHOPEDIC  SURGERY. 

Hueter  injected  sputa  from  phthisical  patients  and  detritus  from 
tubercular  glands  into  the  joints  of  dogs,  and  found  that  it  excited 
in  them  a  synovitis  hyperplastica  granulosa,  as  he  terms  it,  of  the 
same  type  that  one  finds  in  tumor  albus,  etc.,  of  the  human  sub- 
ject. From  this  focus  a  general  tuberculosis  often  developed,  and 
caused  the  death  of  the  animal.'  Also,  he  introduced  the  granula- 
tions from  a  human  tumor  albus  into  the  circulation  of  several 
dogs,  and  caused,  with  much  regularity,  general  miliary  tuberculo- 
sis. Schiiller^  threw  further  light  on  the  relationship  between  joint 
affections  and  general  tuberculosis  by  the  following  experiments: 
Guinea-pigs  and  dogs  were  rendered  tuberculous  by  inhaling  solu- 
tions of  phthisical  sputa  and  tuberculous  detritus  for  half  an  hour 
a  day  for  several  days,  and  by  the  occasional  injection  into  their 
lungs  of  the  same  solutions.  The  knee-joint  of  each  was  then 
wrenched  or  violently  contused,  and,  with  a  few  exceptions,  a  syn- 
ovitis granulosa  hyperplastica  of  a  purely  tuberculous  type  followed 
in  the  injured  joint,  while  but  few  tubercles  were  found  in  the 
lungs.  Similar  injuries  to  healthy  animals  caused  no  such  joint 
disease.  Barwell^  takes  exception  to  these  experiments,  and  con- 
siders that  Schiiller's  experiments  conclusively  prove  "  that  a  tuber- 
cular state  of  the  body  does  not  produce  joint  disease.  In  other 
words,  the  earlier  phases  of  joint  disease  are  not  tuberculous," 
chiefly  on  the  ground  that  in  only  six  of  the  twenty-four  animals  were 
structures  like  tubercles  found  in  the  granulations  of  the  diseased 
joints,  and  these  structures  Barwell  considers  as  purely  inflamma- 
tory. He  is,  however,  the  only  author  of  note  who  rejects  Schiil- 
ler's very  careful  work,  and  his  article  is  not  convincing  or  modern. 

Miiller'*  showed  very  clearly  the  channel  of  infection  by  which 
the  bacilli  enter.  Tubercular  material  was  injected  into  the  femoral 
artery  of  sixteen  rabbits  with  no  results,  next  into  the  crural  arte- 
ries (whence  come  the  bone  nutrient  arteries)  of  ten  other  rabbits, 
and  in  some  were  found  tuberculous  bone  lesions.  Finally,  the 
nutrient  arteries  were  found,  and  into  them  alone  the  tuberculous 
material  was  injected  in  twenty  goats,  and  some  dogs  and  sheep. 
The  goats  alone  yielded  positive  results,  most  of  those  whose 
arteries  were  injected  showing  typical  focal  tuberculous  disease  of 
the  ends  of  the  bones.  One  young  goat  was  well  for  four  months, 
then  he  began  to  limp,  and  at  the  end  of  thirteen  months  his  knee- 
joint  showed  a  typical  fungous  joint  disease,  beginning  as  a  cheesy 
focus  in  the  bone  with  a  wedge-shaped  sequestrum  and  several 
tuberculous  foci  around  it. 

'  H.  Hueter  :  Deutsch.  Arch.  f.  Chir. ,  1879,  xi.,  317, 

^  Schiiller :  Cent.  f.  Chir.  for  1878,  v.,  p.  43. 

3  Lancet,  August  2d,  1884.  4  Cent.  f.  Chir.,  No.  14,  1886. 


THE  PATHOLOGY  OF   CHRONIC  JOINT  DISI'.ASE.  223 

Sternberg,'  on  the  other  hand,  failed  to  produce  tuberculosis  in 
animals  by  the  injection  of  inorganic  material  into  their  circulation. 
Garr6,^  using  the  pus  from  cold  abscesses,  nujstly  of  joint  origin, 
found  specific  bacilli  present  in  only  a  small  number,  and  attempts 
at  cultivation  in  these  gave  no  results;  but  this  pus  injected  into 
animals  caused  general  tuberculosis.  More  recently  still,  Triconi^ 
put  phthisical  sputa  and  pus  from  this  class  of  diseased  joints  into 
the  epiphyses  and  diaphyses  of  the  bones,  with  the  result  of  start- 
ing up  a  disease  like  bone  tuberculosis  in  the  human  being,  and 
once  a  bone  injection  caused  also  a  synovitis. 

Burdon  Sanderson  and  Klein  have  obtained  practically  the  same 
result  from  inoculation  experiments,^  and  those  of  Villemin  are 
historical. 

So  much  for  experimental  inoculation  in  animals ;  the  generaliza- 
tion of  tuberculosis  from  a  diseased  joint  in  the  human  subject  is 
a  process  unfortunately  of  such  common  occurrence  that  it  can  be 
passed  over  very  briefly,  and  it  shows  even  more  clearly  than  ex- 
perimental inoculation  the  relationship  of  tuberculosis  and  this 
class  of  joint  disease.  A  few  figures  may  show  the  great  liability 
of  this.  Bilroth  found  that  fifty-four  per  cent  of  patients  dying 
with  this  form  of  joint  disease,  die  of  acute  miliary  tuberculosis; 
Jaffe,  that  fifty-three  per  cent  of  the  deaths  are  from  general  tuber- 
cular infection.  Grosch's^  extensive  statistics  show  that  in  hip 
disease  tuberculosis  is,  in  spite  of  antiseptic  precautions,  the  com- 
monest cause  of  death.  Nor  does  the  removal  of  the  diseased  joint 
seem  to  diminish  this  liability  very  much.  Konig^  did  117  resec- 
tions for  this  class  of  joint  diseases,  and  of  25  deaths  found  18  due 
to  general  tuberculosis,  and  9  more  patients  hopelessly  tubercu- 
lous; and  he  has  more  recently  called  attention  to  the  danger  of 
"  operative  tubercular  infection,"  where,  by  opening  the  lymphatic 
and  blood  channels  in  an  operation  which  at  the  same  time  stirs  up 
the  focus  of  disease,  tuberculous  material  is  carried  over  the  body, 
and  general  tuberculosis  results. 

Caumont '  found  no  preventive  effect  in  resection,  for  in  twenty- 
six  cases  of  hip  disease,  treated  expectantly,  one-fifth  died  of  gen- 
eralized tuberculosis,  while  twelve  others  were  resected  and  one- 
third  died  of  the  same  cause.     Yale^  says,  in  quoting  it,  "  Others 

^  N.  Y.  Medical  Journal,  p.  325,  1SS4. 

^  Garre  :  Deutsch  Med.  Woch.,  No.  34,  1886. 

3  Triconi  :  Baumgarten's  Jahresbericht,  ii.,  p.  229,   18S6. 

4  Quoted  by  Dennis,  N.  Y.  Med.  Ass.  Rep.,  ii.,  p.  331. 

5  Grosch  :    Cent.  f.  Chir.,  228,  1SS2. 

^  Konig  :  Archiv  f.  Klin.  Chir.,  26,  p.  822. 
7  Caumont :  Deutsch.  Z.  f.  Chir.,  xx.,  137. 
^  Yale  :  N.  Y.  Medical  Journal,  November  2Sth,  18S5. 


224 


ORTHOPEDIC  SURGERY. 


may  have  had  better  results,  but  the  prophylactic  effect  cannot  be 
very  decided,  if  such  marked  exceptions  occur."  Esmarch  agreed 
with  Konig  as  to  the  small  preventive  value  of  resection. 

This  is  the  evidence  for  considering  this  form  of  chronic  ostitis 
as  tubercular;  and  there  seems  no  need  of  any  extended  argument 
to  demonstrate  that  such  is  the  fact  so  far  as  modern  pathology 
can  guide  us  to  any  conclusion. 

Gunimatoits  Ostitis. — Beside  the  tubercular  form  of  degenerative 
ostitis,  one  finds  a  form  characterized  by  the  formation  of  gummata. 

It  is  the  less  common  form  of  degenerative  ostitis  which  affects 
the  subjects  of  tertiary  and  hereditary  syphilis.  This  is  character- 
ized by  the  formation  of  gummata,  in  the  spongy  tissue  of  the 
epiphyses,  or  more  commonly  in  the  periosteum;  but  a  much  more 
common  location  still  is  in  the  shaft  of  the  bone,  so  that  it  does 
not  appear  as  a  joint  disease  at  all  in  most  cases,  but  as  an  affection 
of  the  shafts  when  it  occurs  at  the  ends  of  the  bones. 

It  is  not  common  for  the  epiphysis  to  be  affected  before  the 
synovial  membrane,  but  it  does  occur,  although  synovitis  is  much 
more  common  from  this  cause.  On  section  the  bone  shows,  most 
often  in  the  periphery,  a  yellowish-gray  focus  of  disease,  in  appear- 
ance strikingly  like  the  early  stage  of  focal  tuberculosis.  But  from 
this  latter  it  may  be  distinguished,  according  to  Schiiller,  by  the 
absence  of  any  surrounding  hyperasmia  or  infiltration,  which,  he 
says,  always  goes  with  tuberculous  disease.  Often,  of  course,  these 
gummata  exist  along  with  much  synovitis  of  a  characteristic  type, 
and  a  much  thickened  and  diseased  periosteum.  Gummata  in  the 
periosteum  appear  as  elastic  swellings,  rich  in  fluid,  poor  in  cell- 
elements;  later  they  degenerate  to  stuff  like  pus  and  by  fatty  de- 
generation and  absorption  a  cheese-like  substance  and  scar-tissue,, 
and  finally  only  a  thickening  remains. 

Secondarily  to  these  periosteal  and  bone  lesions  come  the  capsu- 
lar and  synovial  thickening,  and  the  cartilage  degenerations  noted 
above. 

One  special  form  of  syphilitic  disease  deserves  mention,  syphilitic 
osteochondritis  with  accompanying  epiphyseal  periostitis  and  peri- 
chondritis, as  Ziegler  calls  it.  Before  the  joint  is  infected,  one 
finds  a  circular  swelling  around  the  epiphysis ;  this  is  a  periostitis 
with  much  spongy  tissue  under  the  periosteum,  which  later  affects 
the  joint  perhaps  with  a  destructive  purulent  synovitis,'  as  a 
subacute  or  chronic  synovitis  with  much  effusion  and  thicken- 
ing.^    Occasionally  the  inflammatory  process  is  of  such  a  character 

'  Langenbeck's  Archiv  f.  Chir. ,  28,  Heft  2. 

^Somma:  Giornale   Internazionale  di  Sc.  Mediche,  1882;  Cassell:  Archiv  f.  Khde., 
1884-85. 


THE  PATHOLOGY  OF  CHRONfC  JOINT  DISEASE.         225 

that  the  epiphysis  is  loosened   from  the   shaft  by  the  destructive 
process. 

To  make  the  diagnosis  of  syphilis  and  tuberculosis  from  the 
pathological  appearance  of  the  bone  alone  might  occasionally  be 
difficult,  but  aided  by  clinical  characteristics  there  would  not  often 
be  much  difficulty. 

The  microscopical  structure  of  the  focus  of  disease  in  these  cases 
shows  a  typical  gummatous  structure. 

ArtJij'itis  Deformans. — Leaving  the  question  of  degenerative  osti- 
tis as  it  affects  the  joints,  one  comes  to  a  joint  disease  secondary 
to  the  opposite  condition,  formative  ostitis.  This  affection  is 
known  by  a  multiplicity  of  names,  of  which  the  following  are  the 
principal  ones. 

Rheumatic  gout,  chronic  rheumatic  arthritis,  arthrite  seche,  ar- 
thritis deformans,  osteoarthritis,  nodosity  of  the  joints,  rheumatoid 
arthritis,  nodular  rheumatism,  dry  arthritis,  proliferating  arthritis, 
malum  senile,  chronic  articular  rheumatism.  The  name  arthritis 
deformans  will  be  adopted  here,  inasmuch  as  it  describes  the  con- 
dition and  involves  no  etiological  theory. 

It  is  a  question  just  where  this  form  of  joint  disease  belongs  in 
the  present  classification,  for  the  condition  has  been  asserted  to 
have  its  origin  in  the  .bone,'  the  synovial  membrane  (R.  Adams  and 
Brodie,  Volkmann,  Cruveilhier),  and  the  cartilage  (Marsh,  Orth, 
Billroth,  Cornil  and  Ranvier). 

And  although  weight  of  modern  authority  places  its  ordinary 
origin  in  the  cartilage  or  the  cartilage  and  synovial  membrane,  the 
bone  changes  ultimately  assume  so  great  prominence  that  it  seems 
best  to  consider  it  here. 

There  is  a  thickening  of  the  synovial  membrane,  a  hypertrophy 
of  the  fringes,  and  finally  the  development  of  the  shaggy  surface 
already  spoken  of.  The  changes  in  the  cartilage  are  of  the  usual 
type  of  cartilage  inflammation,  only  more  severe.  The  hyaline 
substance  becomes  fibrillated,  and  where  there  is  pressure  it  is  worn 
away  in  small  patches  or  large  surfaces,  exposing  the  bony  lamella, 
which  speedily  becomes  polished  and  ivory-like  from  the  friction. 
The  same  process  of  cartilage  degeneration  taking  place  atvthe 
periphery  of  the  joint  results  differently.  There  is  sufficient  free- 
dom from  pressure  to  wear  away  the  degenerated  substance,  and 
the  covering  of  synovial  membrane  retains  the  proliferated  corpus- 
cle cells,  which  remain  and,  taking  on  a  formative  activity,  make 
the  marginal  hypertrophies  or  ecchondroses  already  mentioned ; 
but  sometimes  these  perforate  the  synovial  membrane  and  become 
intra-articular,  and  often  break  off  to  form  loose  bodies ;    at  other 

'  Barwell,  loc.  cit.,  p.  3S5. 

^5 


226  ORTHOPEDIC  SURGERY. 

times  they  grow  laterally,  and  do  not  encroach  upon  the  joint. 
Inasmuch  as  these  ultimately  oseify,  an  explanation  of  the  extreme 
changes  in  the  shape  of  the  ends  of  the  bones  is  afforded,  easily 
transforming  a  globular  to  a  flat  end,  and  so  limiting  very  seriously 
the  arc  of  motion  of  the  joint. 

The  changes  in  the  bones  are  in  the  first  instance  the  result  of 
the  wearing  away  of  the  cartilage  covering  the  ends,  and  the  con- 
sequent friction  and  eburnation  of  the  articular  ends  with  an  irrita- 
tion of  them.  This  irritation  results  in  hyperaemia  which  is  neces- 
sarily attended  by  a  slight  degree  of  rarefying  ostitis. 

But  after  the  enlargement  of  the  Haversian  canals,  and  the  de- 
generation of  the  bone-cells,  a  formative  activity  springs  up  in  the 
periosteum  and  in  the  endosteum  covering  every  one  of  the  cancel- 
lar  walls,  and  a  compact,  "  eburnated  "  layer  is  quickly  made  which 
covers  the  exposed  end,  under  which  layer  a  formative  activity  is 
going  on  while  the  polished  surface  is  always  being  worn  away; 
and  to  this  constant  wearing  away  is  due  the  "  worm-eaten  "  ap- 
pearance so  generally  spoken  of,  which  is  due  to  the  exposing  of 
the  ends  of  the  Haversian  canals.  But  while  pressure  and  friction 
are  wearing  away  the  centre  of  the  articular  ends  of  the  bones,  the 
margins,  where  pressure  and  friction  are  slight,  are  rapidly  prolif- 
erating. Hypertrophy  of  the  cartilages  here  affords  a  field  for  the 
deposit  of  lime-salts,  and  the  hypertrophic  bony  enlargement  is 
closely  bound  up  with  the  development  and  increase  of  the  margi- 
nal ecchondroses  so  often  alluded  to,  their  growth  goes  on  super- 
ficially, while  ossification  takes  place  in  the  deeper  layers  by  a 
process  similar  to  physiological  ossification.  These  lumps  inter- 
nally, then,  are  bony,  superficially  they  are  cartilaginous.  Growing 
out  with  surprising  rapidity,  they  form  a  buttress-like  growth  which 
speedily  restricts  the  motion  of  the  joint,  although  true  ankylosis 
rarely  or  never  takes  place,  the  stiffness  and  loss  of  joint  movement 
being  due  to  this  ensheathing  bony  growth. 

Degeneration  of  the  ligaments  occurs  early  in  the  affection ;  they 
become  inflamed  and  then  thickened,  and  finally  they  degenerate 
into  a  condition  where  they  resemble  fibro-cartilage  or  elastic  tis- 
sue, and  in  virtue  of  this,  the  affected  joints  may  show  decided 
lateral  mobility. 

Finally,  at  the  attached  border  of  the  capsule  as  well  as  in  the 
ligaments  themselves,  there  begins  a  dense  bone  formation  which 
contributes  to  the  ensheathing  bony  mass.  The  osteophytes  are 
more  rounded  and  flat  than  one  is  accustomed  to  see  in  bone  for- 
mation after  fractures,  e.g.,  and  from  the  fact  that  ossification  is 
not  preceded  by  any  especial  vascularity,  the  new-formed  bone  is 
more  dense    and    compact   than    normal;    the    tissues   ossify   just 


THE  J'ylTHOLOGV  OF   CHRONIC  JOINT  JJ/SJiAS/C.  227 

as  they  are.  The  muscles  controlhng  the  joint  atrojjliy  from  dis- 
use, and  the  tendons  are  "  absorbed  "  as  well  as  the  intra-capsu- 
lar  ligaments.  "The  absorption  of  tendons  is  best  illustrated  in 
the  shoulder,  where  that  part  of  the  long  tendon  of  the  biceps 
which  lies  within  the  capsule  is  often  found  displaced  from  its 
groove  and  frayed  out,  or  completely  worn  through,  and  its  two 
ends,  separated  by  a  considerable  interval,  are  adherent  to  the 
subjacent  bone."  ' 

Synovial  effusion  is  often  present  for  a  while  at  the  beginning  of 
the  affection,  but  it  never  occupies  more  than  a  subordinate  place 
and  suppuration  practically  never  occurs. 

In  the  late  stages  there  is  apt  to  be  peri-articular  oedema  of  the 
affected  joint,  and  the  skin,  even  before  that,  becomes  thin  and 
drawn,  and  shoAvs  most  plainly  the  deformed  outline  of  the  joint. 

Exostoses. — Apart  from  the  changes  of  arthritis  deformans  there 
sometimes  occur  exostoses  about  the  articular  ends  of  the  bones, 
which  are  very  rarely  large  enough  to  impede  the  motion  of  the 
joints,  at  other  times  they  are  troublesome  by  involving  tendons  in 
their  growth. 

They  are  of  two  kinds.  First,  small  spur-like  processes  or 
rounded  projections,  the  result  either  of  an  inflammatory  process, 
or  of  a  simple  hypertrophy;  and  several  large  lobulated,  spongy 
masses  of  bone  called  diffused  osteoid  tumors,  which  occasionally 
involve  and  destroy  a  joint,  as  in  the  cases  of  Paget'"  and  Lance- 
reaux,3  where  the  knee-joint  was  so  badly  involved  by  the  growth 
of  one  of  these  osteoid  tumors  from  the  tibia  and  femur  that  am- 
putation was  necessary.  In  structure  they  all  show  typical  bone 
formation,  and  both  classes  belong  rather  to  the  order  of  patho- 
logical curiosities. 

Ttcmors  of  the  Joints. — Tumors  involving  the  joints  are  malignant 
or  benign.  In  the  latter  class  are  to  be  named  exostoses,  cartilag- 
inous tumors,  angioma,  aneurism,  and  echinococcus.  The  last 
three  are  only  pathological  curiosities;  exostoses  have  been  con- 
sidered under  formative  ostitis.  Cartilaginous  tumors  grow  from 
the  peripheral  or  central  part  of  the  bone,  they  occur  chiefly  on 
the  joints  of  the  hands. 

Malignant  tumors  are  of  vastly  more  importance.  There  is  a 
tendency  among  certain  writers  (Billroth,  Marsh,  etc.)  to  identify 
all  malignant  joint  tumors  with  sarcoma,  ignoring  the  existence  of 
carcinoma.  The  existence  of  primary  cancer  of  bone  is,  however, 
attested  by  Virchow,  Volkmann,  Forster,  Paget,  and  Barwell.  Sar- 
coma is,  however,  vastly  more  common,  and  it  occurs  in  many  his- 

'  Howard  Marsh  :    "  Dis.  of  Jts.,"  p.  59.  1SS6. 

^  "  Surg.  Pathology,"  vol.  ii.,  p.  506.  3  Holmes'  "  Surgerj-,"  iii.,  S25. 


228 


ORTHOPEDIC  SURGERY. 


tological  forms,  round  and  spindle-celled,  myeloid,  partly  cartilagin- 
ous and  (rarely  near  the  ends  of  the  bones)  partly  ossified,  as  the 
osteo-sarcoma.  The  growth  originates  occasionally  in  the  synovial 
membrane,  ordinarily  in  the  bones  from  the  endosteum  or  perios- 
teum. The  latter  infil- 
trates soft  parts  of  bone, 
and  on  section  appears 
fleshy  and  mottled,  be- 
ing most  often  com- 
posed of  myeloid  or 
giant  cells.  The  endos- 
teal form,  however,  is 
ordinarily  the  spindle- 
celled  form  and  grows 
less  rapidly,  absorbing 
the  bone  and  having  the  ap- 
pearance of  having  a  cap- 
sule, which  it  really  does 
possess.  Joint  sarcomata 
chiefly  young  subjects 
from  fifteen  to  twenty  or  twenty- 
five  years  of  age.  The  joints 
commonly  affected  are  the  knee, 
the  shoulder,  and  the  wrist. 

The  condition  of  the  perios- 
teum must  be  alluded  to  before 
leaving  the  subject  of  joint  dis- 
ease beginning  in  bone.  There 
is,  of  course,  a  certain  amount 
of  periosteal  thickening  as  the 
result  of  the  hyperaemia  and  gen- 
erally heightened  nutrition  of 
tuberculous  and  gummatous  os- 
titis. Primary  disease  of  the 
periosteum  is  very  rare  as  the 
beginning  of  joint  disease,  but  it 
may  occur  in  both  tuberculosis 
and  syphilis.  Periosteal  thick- 
ening is  so  constant  an  accom- 
paniment of  epiphyseal  ostitis 
that  in  hip  disease,  e.g.,  it  forms  an  important  diagnostic  sign. 

Before  leaving  the  subject  of  ostitis  as  the  beginning  of  joint  dis- 
ease, one  or  two  of  the  less  common,  but  still  possible  varieties, 
must  be  mentioned. 


Fig.  253. — Tumnr  of  the  Bone  Involving  thejoint. 
^From  a  Photograph.) 


THE  I'ATJ/OLOGV  OF   CHRONIC  JOINT  DISEASE.         229 

Simple  07'  ti'aninaiic  ostitis  secondarily  affecting  the  joints  is  very 
unusual.  In  the  traumatic  form,  one  finds  blood  effused  and  in- 
flammatory processes  beginning,  of  the  kind  described  above  as 
typical,  the  periosteum  is  infiltrated,  and  the  bone  marrow  filled 
with  a  fluid  cellular  exudation.  Then  it  depends  upon  circum- 
stances whether  absorption  will  take  place,  or  whether  pus  forma- 
tion will  begin,  and  the  trabeculae  will  be  absorbed  and  the  bone 
broken  down,  or  whether  the  whole  affair  will  take  on  the  tubercu- 
lous type  and  run  the  course  of  that  affection.  If  no  infection 
comes,  wounds,  tears  of  the  joint  capsule,  fractures,  etc.,  result  in 
only  a  serous  or  fibrinous  or  bloody  effusion  into  bone,  joint,  and 
capsule;  but  where  the  bone  is  opened  to  infection,  destruction  and 
necrosis  is  only  too  apt  to  result. 

Lastly  there  is  acute  infections  osteo-inyelitis,  which  sometimes 
affects  the  epiphyses  of  the  long  bones,  and  in  that  way  seconda- 
rily infects  the  joints.  It  begins  in  the  bone  marrow  or  the  perios- 
teum. The  marrow  becomes  hyperaemic,  the  periosteum  infiltrated 
and  thickened ;  soon  in  both  are  seen  beginning  foci  of  pus,  and 
sometimes  hemorrhages  in  their  tissue;  soon  pus  formation  ob- 
scures everything,  and  the  bone  fairly  melts  away;  large  collections 
of  pus  may  form  between  bone  and  periosteum.  Ordinarily  this 
affects  the  shafts  of  bones,  but  sometimes  the  epiphysis,  and  sec- 
ondarily the  joint,  become  infected  when  the  foci  of  disease  are 
near  the  joint;  like  the  tuberculous  foci,  they  tend  to  infect  it. 

Cocci  are  constantly  found,'  most  often  staphylococcus  pyogenes 
aureus  and  albus,  and  extensive  necrosis  results. 

IV.  Joint  Diseases  Affecting  Primarily  the  Peri-articular  Structures. 
Ligamentous  Affections. — It  was  formerly  thought  that  diseased  lig- 
aments were  often  the  cause  of  chronic  joint  disease.  William 
Adams  wrote  :  "  Strumous  joint  disease  commences  most  frequently 
in  some  of  the  ligaments  of  the  joints."  To-day  we  know  that  the 
commonest  beginning  of  chronic  joint  disease  is  in  the  bones,  yet 
the  fact  remains,  a  wrench  or  sprain  causing  evidently  injury  to  a 
ligament  (of  perhaps  ever  so  slight  a  character)  is  sometimes  the 
starting  point  of  a  chronic  joint  affection.  Ligaments  are  pecu- 
liarly slow  to  inflame  and  slow  to  repair ;  when  they  are  found  in 
a  state  of  inflammation  they  are  thick  and  pulpy  and  softened. 

In  gout  they  may  be  the  seat  of  the  deposit  of  tophi  before  other 
localities  are  affected. 

Peri-articular  Abscess. — Suppuration  in  the  peri-articular  cellular 
tissue  and  subsequent  affection  of  the  joint,  may  start  from  an 
open  skin-wound  which  has  been  infected,  or  from  an  injury  to  the 

'  Rosenbach  :  Fort,  der  Med.,  iii.,  1885  ;    Garre  :  "  JNIikro-org-anismen  b.  d.  "Wundin- 
fektions-Kkhten.,"  Wiesbaden,  1SS4  ;    Mliller :  Schmidt's  Jahrb.,  vol.  cc\'i.,  p.  2S4. 


230 


ORTHOPEDIC  SURGERY. 


limb  where  cellulitis  has  come  on  in  consequence  of  the  trauma. 
Again,  in  children  of  feeble  type,  peri-articular  abscess  of  a  slow 
and  chronic  character  is  not  unlikely  to  arise  after  slight  bruises, 
and  sometimes  after  no  perceptible  injury  at  all.  Any  of  these 
abscesses,  if  they  are  not  at  once  evacuated,  are,  of  course,  likely  to 
infect  a  neighboring  joint;  occasionally,  the  abscess  from  one  dis- 
eased joint  burrows  a  long  distance,  and  in  its  course,  either  opens 
into  another  joint  or  passes  so  near  to  it  that  infection  of  the 
second  joint  takes  place.  This  may  occur  in  psoas  abscesses,  where 
the  pus  travels  near  enough  to  the  hip  to  infect  it.  This  explains 
a  certain  number  of  the  cases  of  hip  disease  secondary  to  Pott's 
disease. 

Bursitis. — The  inflammation  of  bursae  is  a  question  which  seems 
rather  to  belong  to  general  surgery,  but  certain  of  the  bursas  com- 
municate very  closely  with  important  joints,  and  it  seems  worth 
while  to  mention  some  of  them.  It  is  not  difficult  to  see  that  an 
inflammation  of  one  of  these  may  easily  lead  to  an  affection  of  the 
joint. 

For  example,  the  large  bursa  between  the  neck  of  the  glenoid 
process  and  the  subscapular  muscle  is  ordinarily  in  connection  with 
the  shoulder-joint,  as  is  the  case  more  rarely  with  the  bursa  under 
the  deltoid.  The  bursa  beneath  the  triceps  tendon  is  most  often  a 
prolongation  of  the  elbow  synovial  membrane.  The  bursa  under 
the  psoas  and  iliacus  tendon  frequently  communicates  with  the 
hip-joint,  and  the  bursa  in  the  popliteal  space  often  communicates 
with  the  knee-joint.  These  are  the  common  communications,  but 
at  most  this  is  an  infrequent  cause  of  joint  disease. 

As  other  causes  of  impairment,  rather  than  disease,  of  joints, 
may  be  mentioned  the  following:  cicatrices  after  burns,  wasting 
of  muscles  and  ligaments  after  infantile  paralysis,  and  muscular 
contractions  causing  malpositions  of  the  joints  after  hemiplegia, 
etc. 


CHAPTER    V. 

THE    ETIOLOGY,  COURSE,  AND   TERMINATION   OF 
CHRONIC   JOINT    DISEASE. 

Etiology. — Chronic  Serous  Synovitis. — Chronic  Purulent  Synovitis. — Inflam- 
mation of  Cartilage.— Joint  Manifestations  in  (a)  Tuberculosis,  (d)  Syph- 
ilis, (c)  Rheumatism,  (d)  Arthritis  Deformans,  (e)  Gout,  {/)  Acute  Infec- 
tious Diseases,  (g-)  Miscellaneous  Conditions. — Tabes  Dorsalis. — Haemo- 
philia.— Growing  Pains. — Acute  Arthritis  in  Infants. — The  Distribution 
of  Chronic  Joint  Disease. — Course  and  Termination  of  Chronic  Joint  Dis- 
ease.— Ankylosis. — Treatment  of  Chronic  Joint  Disease. 

The  etiology  of  chronic  joint  disease  is  a  question  of  much  prac- 
tical importance  in  some  of  its  aspects,  especially  in  regard  to  the 
chronic  tuberculous  joint  diseases  of  children.  The  consideration 
of  the  whole  subject  will  be  undertaken  so  far  as  possible  under 
the  same  divisions  which  were  used  in  speaking  of  the  pathology  of 
joint  disease. 

Chronic  serotis  synovitis  which  begins  as  such  and  is  not  the  result 
of  the  acute  affection  is  a  disease  about  whose  cause  very  little  is 
known.  At  times  it  is  impossible  to  determine  the  cause,  while  at 
other  times  it  must  be  assigned  to  some  poor  systemic  condition. 
The  affection  occurs  oftenest  in  young  adults,  especially  young  men, 
and  it  is  far  more  frequent  as  the  outcome  of  one  or  a  series  of 
attacks  of  acute  or  subacute  synovitis.  When  it  begins  as  the 
chronic  affection  it  is  not  as  a  rule  associated  with  the  rheumatic 
or  any  other  diathesis  beyond  a  poor  general  condition. 

Some  authors  consider  it  an  obscure  form  of  osteo-arthritis,'  but 
such  cases  are  most  often  marked  by  the  occurrence  of  marked 
hypertrophy  of  the  synovial  fringes,  and  a  tendency  to  connective- 
tissue  formation.  One  phase  of  the  affection  is  represented  by  the 
intermittent  form  described  by  Seeligmiiller=  where  thirteen  cases 
are  detailed.  In  only  two  cases  could  any  constitutional  cause  be 
assigned,  and  these  suffered  from  intermittent  fever.  The  affection 
has  no  established  pathology  beyond  this.^ 

'  Marsh,  Howard  :    "  Diseases  of  the  Joints,"  p.  76,  1SS6. 
"  Deutsche  Med.  Wochschft.,  18S0,  v.  and  vi. 
3  Nicolayson  :    Cent.  f.  Chir. ,  June  4th,  1887. 


232 


ORTHOPEDIC  SURGERY. 


Certain  classes  of  cases  of  chronic  serous  synovitis,  however,  have 
a  definite  pathological  basis,  and  such  are  instances  of  the  common 
form  of  chronic  serous  synovitis,  where  it  remains  from  the  primary 
affection,  caused  by  a  blow,  wound,  a  strain,  or  exposure  to  cold 
and  over-exertion,  or  in  those  obscure  cases  where  no  cause  is  to 
be  assigned,  which  are  sometimes  called  rheumatic,  on  very  insuffi- 
cient evidence.  Here  the  appearance  is  that  modified  appearance 
of  the  acute  form  described  above.  Next  comes  the  rheumatic 
variety,  the  result  of  a  primarily  rheumatic  synovitis  with  its  ten- 
dency to  relapse  and  to  ankylosis,  and  a  rheumatic  form  without 
any  primary  stage,  occurring  as  a  sequel  or  complication  of  clearly 
marked  rheumatism.  These  forms  are  both  marked  by  hypertro- 
phy of  the  fringes,  and  a  tendency,  in  long-continued  cases,  to  bone 
enlargement  and  tissue  formation ;  and  allusion  is  made  to  pure 
chronic  rheumatism,  not  to  rheumatic  arthritis,  which  will  be  de- 
scribed by  itself.  Syphilis  as  a  cause  of  this  form  of  synovitis  ap- 
pears in  two  phases,  one  in  the  secondary  stage,  where  it  simulates 
the  rheumatic  form  very  closely  and  is  ordinarily  acute,  but  some- 
tirries  it  is  chronic  and  persistent.  At  times  it  is  markedly  inter- 
mittent. If  it  persists  it  leaves  the  joint  enlarged,  indurated,  and 
subject  to  subsequent  attacks.  The  second  form  is  encountered  in 
the  tertiary  stage,  where  it  appears  as  an  infiltration  of  the  synovial 
membrane  and  sub-synovial  tissue  of  a  gummatous  type  (Lance- 
reaux '),  with  a  varying  amount  of  effusion,  and  a  tendency,  if  con- 
tinued, to  enlargement  of  the  bones,  but  not  especially  to  stiffening 
of  the  joint."  Richet^  called  this  "  syphilitic  white  swelling."  "  The 
effusion  may  be  purulent,  but  it  is  also  at  times  serous.  Chronic 
serous  synovitis  occurring  in  hereditary  syphilis  is  often  secondary 
to  bone  or  cartilaginous  affection,^  especially  a  bilateral  painless 
form,  which  attacks  children  from  eight  to  fifteen  years  of  age.  It 
does  not  tend  to  go  on  to  destructive  changes,  though  primary 
forms  are  described.^ 

Gout  and  arthritis  deformans  both  are  occasional  causes  of 
chronic  synovitis. 

Lastly,  gonorrhoea  is  to  be  mentioned  as  a  more  or  less  common 
cause  of  joint  effusion  of  a  chronic  character,  ordinarily  as  a  se- 
quence of  an  acute  or  subacute  synovitis  of  long-drawn-out  course, 
and  in  the  fluid  gonococci  are  to  be  found.'  The  attack  ordinarily 
occurs  in  the  second  or  third  week  of  the  discharge,  and  simulates 
sometimes  the  course  of  rheumatism  and  sometimes  that  of  pyae- 

'  "  Traite  Hist,  et  Prat,  de  Syph."     Paris,  1873. 

^  Follin  :    "  Traite  de  Path,  externe,"  p.  714.  3  Richet :    Mem.  de  I'Acad.,  1853. 

4  Bumstead  and  Taylor:    "Venereal  Diseases,"  p.  837. 

*  Schtiller  :    Cent.  f.  Chin,  1882,  ii.,  p.  32. 

^  Clutton  :    Lancet,  1886,  i.,  391.  ^  Ziegler  :    "  Path.  Anat."     1887. 


ETIOLOGY,  ETC.,    OE   CIIRONIC  JOINT  J)ISEASI:.^        233 

TTiia;  women  are  rarely  attacked  by  it.  The  discussion  of  the  eti- 
ology of  the  tuberctdous  affection  will  be  postponed  until  the  con- 
sideration of  the  more  common  forms  of  joint  tuberculosis,  those 
occuring  primarily  in  the  bone. 

Chronic  purulent  synovitis  is  sometimes  the  result  of  an  acute 
serous  or  purulent  synovitis,  but  the  tendency  of  acute  synovitis 
in  healthy  individuals  is  not  to  run  on  to  this  form ;  when  this 
occurs  it  is  most  often  in  adults  of  feeble  constitution  and  in  chil- 
dren of  the  feebly  resistant  type  described  as  strumous,  tubercu- 
lous, and  scrofulous.  It  occurs  primarily  in  a  very  large  number 
of  cases  as  a  chronic  affection. 

The  etiology  of  primary  inflanniiation  of  cartilage  is  extremely 
obscure.  In  some  of  the  cases  reported  it  was  traumatic  in  origin, 
in  others  no  cause  was  assignable.  .  Some  patients  were  old,  others 
young;  in  fact,  there  seems  nothing  to  indicate  the  cause. 

The  etiology  of  secondary  inflammation  is  to  be  sought  in  the 
cause  of  the  primary  affection — ^trauma,  tuberculosis,  a  penetrating 
wound  of  the  joint,  or  whatever  may  be  at  the  root  of  the  synovitis 
or  ostitis.  Reyher  described  a  change  in  the  cartilage  due  to  dis- 
use of  the  joint  characterized  by  a  slow  inflammatory  process, 
which  he  produced  by  immobilizing  for  weeks  the  limbs  of  some 
dogs. 

Fatty  degeneration  of  cartilage  is  an  ill-defined  process  accom- 
panying the  later  stages  of  chronic  synovitis,  occurring  in  old  age 
and  as  a  subordinate  process  in  rheumatoid  arthritis.  But  here 
fibrillary  degeneration  is  the  characteristic  form,  along  with  the  in- 
creased bone-formation,  but  fibrillary  degeneration  pure  and  simple 
is  the  expression  of  the  general  morbid  condition  known  as  rheu- 
matoid arthritis.' 

Certain  constitutional  pathological  conditions  have  a  most  im- 
portant part  in  the  causation  of  chronic  joint  disease.  The  chief 
ones  are : 

{a)  Tuberculosis. 

{b)  Syphilis. 

{c)  Rheumatism. 

{d^  Arthritis  deformans. 

{e)  Gout. 

(_/)  Acute  infectious  diseases. 

(_^)  Miscellaneous  conditions. 

In  these  the  joint  disease  seems  to  be  merely  the  local  expression 
of  a  general  condition. 

{a)  Tuberculosis. — Formerly  it  was  supposed  that  joint  disease 
of  a  tuberculous  charactei   took   its  origin  in  the  synovial  mem- 

'  Zeitschrift  fi'ir.  Chir. ,  iii.,  iSg. 


234 


ORTHOPEDIC  SURGERY. 


brane,  but  of  late  years,  in  consequence  chiefly  of  the  work  of 
Volkmann  and  Konig  it  has  been  learned  that  tuberculosis  of  the 
joint  begins  usually  in  an  inflammation  of  the  bone.  This  is  invar- 
iably the  case  in  children,  according  to  Volkmann. 

Miiller'  analyzed  232  preparations,  mostly  from  resections,  with 
the  following  result : 


Bone-origin. 

Syn.  origin. 

Indefinite. 

Total. 

Knee 

69 

47 

42 

33 

3 
10 

16 
II 

I 

118 

Hip 

61 

Elbow 

53 

Total              

158 

46 

28 

232 

Age. 


Three  to  fourteen  years.  . 
Fourteen  to  thirty  years. . 
Thirty  years  and  upward. 


Bone. 


50 
64 
39 


Svn. 


18 
12 


Of  71  other  cases  analyzed  by  Konig,""  47  were  osseous,  and  the 
distribution  was  as  follows: 


Bony. 

Syn. 

Hip 

8 

17 
II 

3 

8 

7 

6 

Knee 

Foot. 

Shoulder 

7 
I 

Elbow 

2 

Volkmann  ^  believes  that  fungous  joint  diseases  begin  usually,, 
and  in  children  always,  as  a  localized  ostitis  limited  to  a  spot  in 
the  epiphysis.  Unhappily  figures  bearing  on  the  subject  beyond 
those  given  above  are  very  scanty.  The  whole  classification  of  this 
class  of  diseases  had  been  very  imperfect  until  recently  the  dis- 
covery of  tubercles  in  fungous  joint  disease  has  revived  the  term 
tuberculous,  common  among  French  writers  but  discarded  until  the 
discovery  of  the  tubercle  bacillus  in  the  fungous  granulations  of 
these  affections. 

The  histological  identity  of  the  structures  found  in  chronic  fun- 
gous joint  disease  has  been  abundantly  established.  The  frequency 
with  which  these  are  found  has  been  more  fully  discussed  in  speak- 
ing of  the  pathological  appearances. 

The  reasons  for  considering  these  affections  tuberculous  have 
been  fully  given  in  the  preceding  chapter. 

Heredity  in  the  Causation  of  Tuberculous  Joint  Disease. — In  the 

'  Miiller-Konig :    "  Die  Tuberc.  der  Knochen  und  Gelenke."     Berlin,  1884. 

^  Konig:    D.  Z.  f.  Chir.,  xi.,  1879.  '  "Samml.  kl.  Vortrage,"  168  and  i6g. 


ETIOLOGY,  ETC.,    OF   CHRONIC  JOINT  DISEASE.  235 

causation  of  this  form  of  joint  disease,  characterized  f;y  the  forma- 
tion of  tubercles,  much  stress  has  always  been  laid  upon  the  inher- 
itance of  what  has  been  called  a  "scrofulous  tendency,"  an  inher- 
ited vice  of  constitution.  The  use  of  the  word  "scrofula"  has 
intentionally  been  avoided  here,  and  the  reader  is  referred  to  Mr. 
Treves'  "  Manual  of  Surgery  "  for  a  discussion  of  the  relation  of 
scrofula  and  tuberculosis.  Recent  writers  maintain  (although  this 
is  by  no  means  generally  accepted)  that  tuberculosis  is  a  chronic 
infectious  parasitic  disease,  and  that  scrofula- — although  presenting 
certain  modifications  arising  from  the  difference  of  the  tissues  in 
which  it  is  seated — is,  from  a  pathological  point  of  view,  identical 
with  tuberculosis  (H.  Marsh,  "  Disease  of  Joints,"  p.  97). 

Experimental  investigation  has  shown  clearly  enough  the  possi- 
bility of  the  transmission  of  tuberculosis  .from  parent  to  offspring. 

Landouzy  and  Martin,'  taking  a  six  and  one-half  months'  foetus 
born  of  a  phthisical  mother,  found  it  to  all  appearances  perfectly 
free  from  tuberculosis;  yet  a  piece  of  its  lung  put  into  a  guinea- 
pig's  stomach  caused  general  tuberculosis  in  four  months,  and  in- 
oculation was  then  carried  through  five  animals.  The  cardiac 
blood  from  another  foetus  caused  the  same  tuberculosis  in  other 
guinea-pigs.  Again,  one  of  these  tuberculous  guinea-pigs  gave 
birth  to  a  litter,  and  a  young  one  two  days  old  was  killed  and  ap- 
peared perfectly  healthy ;  yet  pieces  of  its  viscera  inoculated  into 
other  guinea-pigs  caused  general  tuberculosis.  And  finally,  the 
semen  of  a  guinea-pig  thus  rendered  tuberculous  was  removed  from 
the  vesiculae  seminales  with  much  care,  and  being  inoculated  into 
other  guinea-pigs,  caused  tuberculosis. 

Figures  which  attempt  to  show  what  proportion  of  children  with 
joint  disease  inherit  a  tendency  to  these  diseases  are  notoriously 
untrustworthy.  In  the  class  of  hospital  patients  from  whom  most 
of  these  statistics  come,  anything  approaching  accurate  informa- 
tion with  regard  to  the  diseases  of  which  relatives  have  died  Can- 
not be  expected.  There  is  also  an  inclination  on  the  part  of 
parents  to  deny  the  existence  of  tuberculous  disease  in  their  parents 
and  relatives.  In  this  way  parents  of  all  classes  are  much  more 
anxious  to  establish  some  traumatic  cause  for  the  affection  of  the 
joint  than  to  have  it  supposed  that  the  child  inherited  any  consti- 
tutional taint. 

Again  it  must  be  remembered  that  about  \ofo  of  all  deaths  are 
•from  phthisis,  and  that  phthisis  must,  therefore,  necessarih'  appear 
in  the  family  histories  of  a  certain  proportion  of  any  group  of  in- 
dividuals whose  antecedents  are  inquired  into. 

For  these  reasons  the  following  statistics  cannot  be  regarded  as 
'  "  Faits  clin.  et  exper.  pour  servir  a  I'hist.   de  I'heredite  de  la  tuberculose." 


236  ORTHOPEDIC  SURGERY. 

Other  than  inaccurate,  and  only  approximating  the  truth,  but  the 
error  is  likely  to  lie  always  on  one  side,  in  making  the  proportion 
of  inheritance  too  small. 

Gibney'  analyzed  596  cases  of  different  tubercular  joint  diseases, 
and  has  found  tubercular  disease  in  one  or  both  parents  in  sixty- 
eight  per  cent,  and  what  he  calls  an  "  acquired  diathesis  "  in  thirty 
per  cent  more;  and  of  the  whole  number,  after  a  close  investiga- 
tion, he  could  only  find  one  case  which  did  not  present  an  acquired 
or  hereditary  diathesis;  but  he  represents  an  extreme  point  of  view 
in  the  matter.  C.  Fayette  Taylor,""  in  the  analysis  of  845  cases  of 
Pott's  disease,  found  thirty-four  per  cent  where  there  was  tubercu- 
lar or  so-called  scrofulous  disease  in  the  parents,  and  in  sixty-six 
per  cent  the  disease  came  on  in  patients  of  a  sickly  diathesis. 

In  401  cases  of  hip  disease  from  the  Alexandra  Hospital  reports, 
twenty-four  per  cent  had  phthisis  in  the  family  history  ^  and  thirty- 
five  per  cent  were  classed  as  traumatic.  Albrecht,  tabulating  325 
cases  of  tuberculous  disease  of  various  joints  as  to  etiology,  classed 
thirty-three  per  cent  as  "  associated  with  scrofula." 

The  chief  opponents  of  the  point  of  view  that  these  joint  diseases 
are  oftenest  the  results  of  inheritance,  are  those  who  hold  that  the 
common  cause  is  an  injury  to  the  joint.  Experimentally  it  has 
been  seen  that  trauma  to  the  joint  of  a  tuberculous  animal  will 
cause  tuberculous  joint  disease,  but  that  it  does  not  do  so  in  the 
healthy  animal.  It  has  been  established  that  contusions  and 
wrenches  cause  the  effusion  of  blood  in  the  spongy  tissue  of  the 
bone.  Konig  has  seen  cases  where  tubercles  developed  directly 
from  the  clot,  just  as  in  a  syphilitic  individual  a  gumma  will  develop 
at  the  site  of  an  injury  to  the  bone.  "  There  are  cases  where  the 
swelling  from  the  fall  merges  into  the  tuberculous  swelling."  '* 

It  would,  therefore,  seem  rational  to  assume  that  trauma  caused 
tuberculous  joint  disease  in  children  who  inherited  a  constitutional 
taint.  But  it  becomes  evident  at  once  that  this  is  not  all,  for 
every  surgeon  of  experience  must  have  in  his  mind  cases  where 
joint  disease  of  a  tuberculous  type  has  followed  injury  in  children 
whose  family  histories  were  exceptionally  good. 

Konig  estimates  half  the  cases  as  traumatic ;  Albrecht,  one-sixth  ; 
Croft,  thirty-five  per  cent ;  Gibney,  forty-two  per  cent  (of  which 
seventy-two  per  cent  were  also  hereditary) ;  Taylor,  fifty-three  per 
cent  (in  845  cases) ;  and  Sayre  still  represents  the  extreme  view  on 

'  Gibney  :    "  Strumous  Element  in  Joint  Disease,"  N.  Y.  Med.  Jour.,  July,  1877. 
^  From  preface  of   German  translation  of  "The  Mechanical  Treatment  of  Pott's  Dis- 
ease." 

3  Croft :    Clin.  Soc.  Transactions,  London,  vol.  xiii. 
■♦  Konig:    Deutsch  Z.  fiir  Chir.,  1879,  xi. 


ETIOLOGY,   ETC.,    OE   CHRONIC  JOINT  EJShlA^^E.  237 

this  side  in  maintaining  that  practically  all  arc  traumatic.  Gibney 
observed  845  cases  of  spinal  paralysis  (a  class  of  children  subject 
to  constant  falls  and  injuries),  for  several  years,  and  found  only  4 
complicated  with  joint  troubles.  Roser '  observed  lOO  children  at 
Marburg  with  fracture  of  the  elbow,  and  in  no  case  did  tubercular 
disease  follow.  Shaffer-  says,  "  Experience  proves  that  traumatism 
excites  only  acute  disease,  as  a  rule.  In  those  constitutions  strong 
enough  to  resist  and  repair  the  injury,  these  acute  troubles  soon 
subside.  Under  reverse  circumstances  they  are  apt  to  be  followed 
by  a  chronic  form  of  inflammation  which  may  end  in  suppuration," 
Adams,  Agnew,  Bauer,  Sayre,  Petit,  represent  the  advocates  of 
traumatism.  S.  D.  Gross  believed  that  this  joint  disease  could  not 
exist  without  a  vitiated  constitution.  Volkmann  says,  "  Individuals 
with  fungous  joint  disease  spring,  practically  without  exception, 
from  families  in  which  scrofula  and  tubercle  are  hereditary."  That 
such  is  the  rule,  but  that  exceptions  are  common,  is  the  view  held 
by  Sonnenberg,^  Konig,  Howard  Marsh,  Roser,  and  the  majority  of 
modern  writers. 

In  view  of  all  this  the  safest  view  to  take  is  that,  in  the'  greater 
proportion  of  children  an  inherited  vice  of  constitution  is  present, 
and  that  in  these  cases  traumatism  is  most  liable  to  be  followed  by 
chronic  disease,  but  that  in  certain  cases  traumatism  alone  must  be 
accepted  as  the  causative  factor,  while  in  other  cases  the  disease 
seems  to  have  originated  spontaneously.  It  is  in  these  last  cases 
that  one  finds  the  most  marked  signs  of  ill  health  and  "scrofula." 

The  exanthemata  must  be  mentioned  as  being  the  cause  of  tuber- 
culous joint  disease  in  a  certain  proportion  of  cases,  probably  a 
larger  proportion  than  has  been  suspected.  Measles  and  scarlet 
fever  are  the  most  common  eruptive  diseases  to  be  followed  by 
these  sequelae.  Croft  estimates  that  about  7^  of  chronic  tubercu- 
lous joint  disease  in  children  follows  the  exanthemata,  but  there  are 
very  few  figures  bearing  upon  the  subject.  The  effect  of  the  ex- 
anthemata in  causing  other  forms  of  joint  disease  w^ill  be  alluded  to 
later. 

It  is  probable  that  whatever  continuously  diminishes  the  power 
of  resistance  and  of  repair  in  growing  children  increases  what  may 
be  termed  the  vulnerability  of  the  epiphyses,  and  furnishes  the  soil 
for  the  development  of  tubercle  bacillus  and  the  consequent  results. 

Age. — Tuberculous  joint  disease  is  pre-eminently  a  disease  of 
childhood.     It  is  rarely,  if  ever,  congenital,-*  and  under  one  year  it 

'  Berl.  Klin.  Wochenschrift. 

^Shaffer,  N.  M.:    "Am.  Clin.  Lectures,"  vol.  iii.,  141. 
3  Sonnenberg  :    Arch.  f.  Klin.  Chir.,  iSSi,  xx^^.,  7S9. 
''  Lannelongue,  loc.  cit. 


233 


ORTHOPEDIC  SURGERY. 


is  not  common.  Of  Gibney's  860  cases,  so  often  alluded  to,  84^ 
per  cent  of  all  cases  occurred  before  fourteen.  Of  619  cases  of 
hip  disease  tabulated  by  Mr.  Wright,'  there  were : 


and 


Under  6  years,  . 
From  6  to  10  years, 

"   10  to  15 

"   15  to  20 

"   20  to  25 

"   25  to  30 

"   30  to  35 

"   35  to  40 

"   40  to  50 
Above  54  years, 

Total, 

Two  years  and  under, 
From    2  to     5  years, 
5  to  10      " 
"       10  to  14 


Total,  .         . 

Mr.  Bryant  has  tabulated  360  cases  as  follows 
Under  4  years,    .         ... 
From     5  to  10  years, . 

"       II  to  20       "      . 

"      21  to  30       "      . 

"       31  to  40       "      . 
Above  40  years, .... 

Total, 


40  cases, 
no 
129 

66 

39 
17 

9 

4 

3 

I 


418 

cases 

28 

cases 

62 

a 

81 

(< 

30 

(( 

201 

cases 

126 

cases 

97 

86 

27 

13 

II 

360  cases. 


Taking  Mr.  Wright's  and  Mr,  Bryant's  cases,  and  adding  365 
others. reported  by  Dr.  Sayre,'  we  have  1,344  cases  of  hip  disease, 
of  which  1,000  occurred  under  fifteen  years  of  age. 

This  is  natural  enough,  for  these  tubercular  diseases  affect  chiefly 
the  epiphysis,  and  the  epiphysis  during  its  period  of  greatest  activ- 
ity when  its  blood  supply  is  largest  and  its  tissue  changes  most 
rapid. 

The  records  of  the  New  York  Orthopedic  Dispensary  show  the 
liability  at  different  ages  in  the  cases  of  joint  diseases  of  the  lower 
extremity  treated  for  the  years  1884-1I 


"  Hip  Disease  in  Childhood,"  p.   2. 

L.  A.  Sayre  :    "  Orthopedic  Surgery  and  Diseases  of  Joints." 


EriOLOGY,    ETC.,    UJ''   CHRONIC  JO/NT   PfSEASE.  239 

Under  3.       3  to  5.       5I010.      kjIojs.      151020.    (Jvcr2o. 

Hip 115    316    509    140    47    5' 

Knee 43     69   '  94     28    22    63 

Ankle 12     18     24     18     4     7 

170    403    627    186    'J  I        121 

The  liability  of  the  aged  to  tuberculous  joint  disease  must,  how- 
ever, not  be  overlooked.  The  fact  that  people  over  sixty  are  more 
often  "  scrofulous  "  than  people  between  thirty  and  fifty,  is  noted 
by  Sir  James  Paget/  The  patients  may  be  seventy-five  or  ninety, 
and  cases  of  hip  disease  present  the  same  pathological  appearances 
here  as  in  young  children.  Paget  speaks  of  the  affection  as  one 
which  he  frequently  meets.  The  course  of  the  disease  is  more 
rapid  and  destructive  than  in  the  young,  and  its  etiological  rela- 
tions decidedly  more  obscure. 

The  reasons  given  why  tuberculous  joint  disease  affects  children 
to  so  great  an  extent  are  formulated  as  follows  by  Mr.  Wright,  in 
speaking  of  Hip  Disease: 

I.  Because  in  the  active  period  of  growth  more  change  is  going 
on  and  therefore  more  instability  exists  and  consequently  greater 
liability  to  disease  (Barwell). 

II.  That  childern  are  more  liable  to  falls  and  injuries,  which  are 
such  a  fertile  source  of  joint  and  bone  lesions. 

III.  That  it  is  not  till  after  puberty  that  the  process  of  natural 
selection  has  eliminated  the  weaklings  from  the  stock. 

IV.  That  children  are  kept  quiet  less  easily  than  adults  and 
a  slight  injury  may  develop  into  a  formidable  disease. 

V.  That  tuberculosis  in  general  is  common  in  childhood. 

Sex  is  not  a  factor  of  any  prominence,  but  there  is  a  slightly 
larger  proportion  of  tubercular,  joint  disease  among  boys  than 
among  girls.  Of  619  cases  of  hip  disease  collected  by  Wright,  there 
were  371  males.  Holt,-  in  2,307  cases  of  hip  disease,  found  1,178 
males  and  1,129  females,  but  the  preponderance  is  very  slight,  and 
Mr.  Bryant  thinks  one  sex  as  liable  as  the  other.  Barwell  thought 
that  the  presence  of  phimosis  in  a  measure  accounted  for  this  pre- 
ponderance of  males  in  hip  disease,  at  least,  and  in  100  cases  of  hip 
disease  he  found  83  in  a  condition  of  more  or  less  complete  phimo- 
sis. Wright  examined  63  cases  taken  at  random,  12  of  which  were 
hip  disease,  and  he  found,  that  in  the  hip  disease  cases  sixty-seven 
per  cent  had  phimosis,  while  in  the  others  only  fifty  per  cent.  Dr. 
Sayre  is  an  advocate  of  phimosis  as  an  exciting  cause  of  hip  dis- 
ease. 

^  "Clinical  Lectures  and  Essays.     Senile  Scrofula."     2d  Ed.,  p.  345. 
-  Gibney,  loc.  cit.,  p.  206. 


240 


ORTHOPEDIC  SURGERY. 


There  is  hardly  any  need  of  figures  to  call  attention  to  the  fact 
that  phimosis  is  a  most  prevalent  condition  in  small  boys  both 
healthy  and  diseased.  The  figures  of  Dr.  Roswell  Park,'  however, 
show  this  in  a  series  of  observations  which  he  made  on  150  boys 
of  all  conditions  in  private  and  hospital  practice. 

Number.     Per  cent. 

Class   I.     Cases   permitting   easy  and   perfect  re- 
traction of  the  prepuce,  .....        30  19.62 

Class  II.  Cases  of  slight  or  partial  adhesions  with 

little  or  no  retained  smegma,  ...       48         31-37 

Class  III.  Cases  of  complete  or  nearly  complete 

adhesions  without  stenosis,      ....       36         23.53 

Class  IV.  Cases  where  retraction  was  impossible,         39         25.48 


153        100 

From  this  it  is  easy  to  see  how  phimosis  might  easily  come  to  be 
assigned  as  the  cause  of  any  pathological  condition. 

As  regards  the  social  status  of  these  patients,  it  is  said  tubercular 
joint  disease  is  an  affection  attacking  the  lower  classes  more  fre- 
quently than  children  of  well  to  do  and  better-fed  parents. 

Figures,  however,  to  establish  the  statement  cannot  be  said  to  be 
of  value,  and  statistics  are  taken  chiefly  from  hospital  practice. 
The  disease,  however,  is  unfortunately  not  uncommon  in  people  of 
excellent  or  luxurious  surroundings. 

The  Distribution  of  Chroitic  Tuberculous  Joint  Disease. — The  fre- 
quency with  which  different  joints  are  affected  can  only  be  learned 
by  the  consideration  of  large  groups  of  cases.  Schiiller''  gives  the 
following  table  from  439  cases  of  Socin  and  his  own:  Knee,  35.8; 
hip,  15.9;  elbow,  12.7;  tarsus,  11. 8;  foot,  9.6;  hand,  6,2;  shoulder, 
4.1  per  cent.,  etc. 

Billroth  and  MenzeP  in  1,996  cases  found  the  distribution  as 
follows:  Vertebral  column,  35.2;  knee,  11.9;  head  bones,  10.2;  hip, 
9.4;  sternum,  clavicle,  ribs,  9.2;  ankle  and  foot,  7.5  per  cent. 

Of  421  cases  observed  at  Basle,-*  265  were  classed  as  "caries," 
and  156  as  "  fungous  disease,"  and  their  location  was 


Caries. 

Head,     ....       8.3  per  cent. 
Pelvis,    ....     33.6       " 
Upper  extremities,  22.3        " 
Lower  extremities,  33.6        " 
Multiple,    ...       2.2        " 


Fungous  Disease. 
Upper  extremities,  25.6  percent. 
Lower  extremities,  74.3        " 

Hip, 41 

Knee,      ....     50  " 

Foot,      .     .     ;     .     25  " 


'  Chicago  Med.  Jour,  and  Exam.,  1880,  p.  561. 

^  "  Die  Path,  und  Ther.  der  Gelenkentziindungen,"  Wien  und  Leipzig,  1887. 

3  Arch,  f,  Chir.,  xii.,  1871.  ♦  Deutsch.  Z.  f.  Chir.,  xi.,  1879,  350. 


ETIOLOGY,    ETC.,    OF  CUKOXIC  JOIXT  D/SEASE.  24 1 

Gibney,  in  614  cases,  mostly  in  children,  found  209  cases  of  spinal 
disease;  271  cases  of  hip  disease;  103  cases  of  knee  disease;  31 
cases  of  ankle  disease. 

Five  hundred  and  thirty  cases  of  chronic  joint  disease  of  this 
type  in  children  have  been  observed  in  the  surgical  out-patients  of 
the  Boston  Children's  Hospital,  in  the  last  three  years,  and  they 
have  been  located  as  follows:  Hip,  220;  knee,  64;  ankle,  36;  verte- 
bral column,  202;  shoulder,  3;  elbow,  i;  wrist  and  fingers,  4. 

At  the  New  York  Orthopedic  Dispensary,  dealing  also  almost 
wholly  with  children,  from  1884  to  1886,  inclusive,  there  were  ob- 
served 2,644  cases  of  chronic  joint  disease  of  this  type,  in  which 
there  were,  1,178  cases  of  hip  disease;  1,024  of  vertebral  disease; 
83  of  ankle  disease;  319  of  knee-joint  disease;  7  of  wrist  disease; 
II  of  elbow  disease;  11  of  shoulder-joint  disease;  11  of  multiple 
joint  disease. 

Dr.  Judson'  has  recently  called  attention  again  to  the  great  pre- 
ponderance of  joint  disease  in  the  lower  extremity  as  contrasted 
with  the  upper  limb.  Analyzing  the  reports  of  two  Orthopedic 
Institutions  in  New  York  City  he  finds  that  in  a  single  year  the 
following  number  of  cases  of  disease  of  the  different  joints  were 
treated; 

Hip-joint  disease,  .         .         »         .         .         .     577 

Knee    «'         " 181 

Shoulder        "        .         .         .         .         .         .         .         6 

Elbow  " 8 

or  758  patients  had  disease  of  the  joints  of  the  lower  extremity, 
while  in  the  same  time  there  only  appeared  14  cases  of  joint  dis- 
ease in  the  upper  extremity.  The  conclusion  that  Judson  dra^^■s 
should  be  presented  in  his  own  words : 

*'  The  practical  lesson  to  be  drawn  is  the  necessity  of  imitating 
in  the  lower  the  mechanical  environment  of  the  upper  limb.  The 
lower  extremity  should  be  made  a  pendent  member  by  some  form 
of  crutch,  axillary  or  perineal,  from  the  earliest  recognition  of  the 
disease  till  its  resolution." 

In  joint  disease  where  one  or  more  articulations  are  involved, 
any  combination  may  be  found,  but  the  most  common  are  hip 
disease  and  Pott's  diseafse,  knee  disease  and  Pott's  disease,  and 
double  hip  disease.  Disease  of  both  the  knee  and  hip  joints  is  not 
common,  and  double  tumor  albus  is  very  unusual. 

{b)  Syphilis. — Joint  inflammations  in  syphilis  occur  at  three  stages 
of  the  disease:  (i)  in  the  early  secondary  stage;  (2)  in  the  tertiary 
stage ;  (3)  in  hereditary  syphilis.  Each  of  these  forms  must  be 
mentioned  separately. 

'  N.  Y.  JMed.  Record,  May  i8th,  1889. 
16 


242  ORTHOPEDIC  SURGERY. 

(i)  Coincident  with  the  skin  eruptions,  the  sore  throat,  the  iritis, 
etc.,  of  the  early  general  manifestation  of  the  disease,  there  is  oc- 
casionally, though  not  commonly,  noted  a  simple  serous  synovitis. 
No  post-mortem  examinations  of  joints  in  this  condition  are  re- 
corded. The"  joints  most  commonly  affected  are  in  the  order 
named:  the  knee,  hand,  elbow,  foot,  and  fingers. 

(2)  In  tertiary  syphilis  there  are  two  manifestations  of  what  is 
practically  the  same  pathological  process.  The  development  of 
gummata  in  the  periosynovial  tissues  with  chronic  hyperplastic 
synovitis,  and  later  cartilage  destruction.  And  secondly,  the  de- 
velopment of  gummata  in  the  bone  and  a  secondary  affection  of 
the  joint,  as  we  have  seen  under  degenerative  ostitis. 

(3)  The  joint  manifestations  of  hereditary  syphilis  fall  under  four 
classes,  which  are  sufificiently  well  marked  to  be  considered  sepa- 
rately. 

A  simple  serous  synovitis  attended  with  much  effusion,  and  a 
tendency  to  cartilage  necrosis  in  spots;  the  capsule  may  be  more 
or  less  thickened,  but  the  epiphyseal  cartilage  remains  normal. 

An  osteochondritis  with  an  accompanying  epiphyseal  periostitis 
and  perichondritis,  as  already  considered  under  degenerative  osti- 
tis, with  its  accompanying  chronic  synovitis  and,  worst  of  all,  its 
tendency  to  separate  the  epiphysis  from  the  shaft  of  the  bone. 

A  chronic  serous  hyperplastic  synovitis,  with  papillary  growths 
and  gummatous  changes  of  the  synovial  membrane.  And  lastly, 
joint  inflammation,  the  result  of  syphilitic  ostitis,  periostitis,  and 
osteomyelitis  of  the  long  bones. 

The  classification  followed  is  practically  that  of  Max  Schtiller. 

Syphilitic  joint  disease  attacks  oftenest  the  knee,  then  the  elbow, 
the  small  joints  of  the  fingers,  and  the  toes,  the  metarcarpo-and 
metatarso-phalangeal  joints,  then  the  joints  of  the  hand,  the  hip- 
joint,  the  ankle,  and  the  sterno-clavicular  joints  in  the  order  named. 
In  61  cases  of  syphilitic  joint  disease  collected  from  various  authors, 
the  distribution  was  as  follows:  knee,  22;  joints  of  hands  and  feet, 
20;  the  elbow,  12,  and  the  remainder  about  equally  distributed 
among  the  joints  mentioned  above. 

(c)  Rheumatism  is  an  affection  which  receives  credit  for  the 
causation  of  much  joint  disease  with  which  it  has  really  nothing  to 
do.  The  manifestations  of  arthritis  deformans  are  confused  with 
the  truly  rheumatic  affections,  and  as  in  simple  acute  synovitis  of 
the  knee  where  no  cause  is  assignable  the  disposition  of  many  prac- 
titioners is  to  consider  the  affection  as  "  rheumatic,"  so  in  joint 
disease  in  general,  obscure  cases  are  liable  to  be  placed  in  this  class. 

In  true  rheumatic  joint  affections  the  structure  attacked  is  chiefly 
the  synovial  membrane,  which  secretes  much  fluid  and  takes  on 


ETIOLOGY,   ETC.,    OE  CHRONIC  JOINT  DISEASE.  243 

the  appearances  of  chronic  proliferating  inflammation,  with  a  ten- 
dency to  connective-tissue  formation.  In  long-continued  cases 
the  cartilage  shows  the  signs  of  chronic  inflammation;  thickening 
of  the  ends  of  the  bones  is  not  uncommon.  The  whole  tendency  is 
away  from  suppur^ition  and  toward  connective-tissue  formation. 
One  form,  which  Schiiller  calls  arthritis  rheumatica  ankylopoetica, 
shows  but  little  or  no  effusion,  but  a  tendency  to  the  formation  of 
fibrous,  and  later  bony,  ankylosis.  This  ordinarily  occurs  in  people 
of  lowered  vitality  through  want,  or  use  of  improper  food. 

Rheumatic  joint  affections  attack  oftenest  the  knee,  then  the 
foot,  elbow,  hand,  shoulder,  hip,  etc.  They  are  monarticular  or 
polyarticular,  and  are  either  the  outcome  of  an  acute  joint  rheu- 
matism, or  an  affection  beginning  spontaneously,  or  more  rarely 
they  result  from  some  injury. 

For  the  most  part,  purely  rheumatic  affections  attack  youths  and 
people  of  middle  age. 

(d)  Arthritis  deformans  (or  rheumatoid  arthritis)  is  characterized 
by  the  clearly  marked  series  of  changes  described  as  the  chief 
group  in  formative  ostitis.  In  its  manifestations  it  is  both  monar- 
ticular and  polyarticular,  oftenest  the  latter,  and  its  victims  are 
selected  from  those  who  are  between  the  middle  age  and  old — retro- 
grade changes  in  nutrition  seem  to  be  essential  for  its  development. 
Hoy/  much  of  the  disease  is  of  nervous  origin,  and  how  much  is 
rheumatic,  is  entirely  unknown.  Joints  are  attacked  in  the  follow- 
ing order:  knee,  hip,  shoulder,  elbow,  hand,  foot,  etc.  (Schiiller); 
others  place  the  hand  and  finger-joints  first  in  frequency.  It  is 
more  common  among  men  than  women,  and  women  whose  cata- 
menia  have  ceased  early  are  especially  prone  to  the  disease.  It  is 
not  unknown,  however,  among  children,  perfectly  typical  cases  oc- 
curring in  childhood.  The  affection  may  seem  to  be  the  result  of 
injury,  by  dampness,  or  insufficient  food,  and  often  no  cause  at  all 
can  be  assigned  for  it. 

Attacking  the  hip,  it  is  known  as  "malum  coxse  senile,"  a  per- 
fectly well-defined  affection  clinically. 

{e)  Gout. — The  joint  affection,  which  is  the  manifestation  of  the 
constitutional  malady  known  as  gout,  ordinarily  begins  as  an  acute 
attack,  and  is  followed  by  a  chronic  inflammatory  process,  increased 
by  constant  exacerbations.  The  synovial  membrane  first  presents 
the  appearances  of  acute  inflammation ;  the  cartilage  also  shows 
a  tendency  to  inflammatory  degeneration  and  erosion,  and  on  its 
free  surface  and  in  its  tissue  appears  a  deposit  of  urate  of  soda,  as 
well  as  in  its  capsule  and  periarticular  structures,  which  localized 
deposits  are  known  as  "  tophi."  Bony  ankylosis  may  ensue,  and 
there  is  but  little  tendency  to  suppuration,  unless  the  calcareous 


244 


ORTHOPEDIC  SURGERY. 


deposits  ulcerate  through  the  skin  by  pressure  and  so  open  the 
periarticular  tissue.  The  common  seat  of  the  affection  is  the 
metatarso-phalangeal  joint  of  the  great  toe  (Scudamore  found  one 
hundred  and  forty  out  of  one  hundred  and  ninety-eight  cases  lo- 
cated there),  and  from  that  joint  it  tends  to  invade  the  other  joints 
of  the  foot,  the  joints  of  the  hands,  and  the  knee  and  elbow.-joints. 

Gouty  affections  attack  chiefly  men  of  middle  age  in  the  upper 
classes  who  have  lived  upon  highly  nitrogenous  food  and  have  not 
taken  a  large  amount  of  exercise.  In  consequence  of  the  departure 
from  the  normal  condition,  uric  acid  forms  in  the  blood,  which  is 
deposited  in  the  tissues  as  urate  of  soda,  from  the  presence  of  which 
joint  symptoms  arise. 

(/")  Acute  Infectious  Diseases. — The  acute  infectious  diseases  in 
which  joint  complications  occur  are  as  follows:  measles,  scarlet 
fever,  small-pox,  typhus  fever,  typhoid  fever,  cerebro-spinal  men- 
ingitis, pneumonia,  dysentery,  diphtheria,  erysipelas,  epidemic 
parotitis,  pertussis,  puerperal  fever,  pyaemia,  septicaemia,  malaria, 
gonorrhoea,  and  after  the  use  of  catheters  and  sounds. 

The  pathological  appearances  are  those  of  acute  and  chronic 
serous  or  purulent  synovitis  of  one  or  several  joints.  Sometimes 
the  inflammation  assumes  a  pseudo-membranous  character,  as  oc- 
casionally in  scarlet  fever  and  puerperal  fever.  The  infectious  ma- 
terial ordinarily  reaches  the  joint  through  the  circulation,  but 
sometimes  (as  in  puerperal  fever,  acute  infectious  osteomyelitis,  or 
erysipelas)  from  separate  foci  of  disease,  either  by  the  lymph- 
channels  or  by  direct  extension. 

These  diseases  are  now  almost  universally  attributed  to  the  pres- 
ence in  the  joints  of  micro-organisms  of  infectious  character.  Such 
theories  as  that  of  William  Ord,  e.g.,  that  gonorrhoeal  synovitis  is 
the  result  of  reflex  nerve  disturbance,  have  not  enough  in  their 
favor  to  make  them  acceptable  in  the  present  tendency  of  pathol- 
ogy. Micro-organisms  are  found  in  the  diseased  joints,  and 
in  serous  synovitis  their  character  differs  from  those  in  puru- 
lent synovitis;  it  seems  as  if  the  question  of  whether  the  syno- 
vitis were  to  be  a  mild  serous  one,  or  a  violent  destructive  puru- 
lent form,  was  determined  by  the  kind  of  micro-organism  reaching 
the  joint,  rather  than  on  the  especial  infectious  disease  present. 
In  serous  effusions,  organisms  which  characterize  the  especial  dis- 
ease present  are  found,  and  in  greater  or  less  number  different 
forms  of  pyogenic  cocci;  but  in  purulent  and  phlegmonous  pro- 
cesses one  finds  exclusively  such  organisms  as  staphylococcus  and 
streptococcus  pyogenes  in  enormous  numbers.'  These  facts  have 
'  Arch.  f.  klin.  Chin,  xxxi.,  Heft  2;  Huebner  :  "  Zierassen's  Hdbch.,"2  Auflage,  ii., 
p.  546;  Cent.  f.  Chir.,  1884;  Sitzungsber.  d.  Cong.  f.  Chir.,  1884. 


ETIOLOGY,   ETC.,    01'    CHRONIC  JOINT  DISIIASE.  245 

been  established  in  tlit:  joint  diseases  of  scarlet  fever,  acute  infec- 
tious osteomyelitis,  puerperal  fever,  etc.  It  is  su^^^^ested  that  the 
synovitis  of  rheumatism  is  of  the  same  character,  but  no  evidence 
in  support  of  the  theory  is  to  be  adduced.  Gonococci  have  been 
found  in  gonorrhfjeal  synovitis.'  The  fact  that  synovitis  occasion- 
ally follows  urethral  irritation,  were  gonorrhoea  is  not  present,  is 
well  established,''  e.g.,  after  dilatation  for  stricture. 

Joint  complications  come  oftenest  during  the  full  course  of  the 
general  disease,  when  they  are  apt  to  be  polyarthritic,  but  in  scar- 
let fever  they  generally  come  on  at  the  time  of  desquamation,  and 
in  small-pox  in  the  suppurative  stage.  In  other  affections  they  are 
commonest  toward  the  end  of  the  disease,  as  in  diphtheria,  after 
weeks  or  months  of  gonorrhoea,  and  late  in  dysentery  as  well.  Of 
course,  they  only  occur  in  a  very  small  proportion  of  all  cases  ; 
coming  late  in  the  disease  they  are  much  more  apt  to  affect  only 
one  joint. 

But  little  is  known  of  the  general  liability  of  the  different  joints; 
the  knee  is,  however,  clearly  the  one  most  often  attacked.  With 
regard  to  scarlet  fever,  Thomas^  found  the  small  joints  of  the  ex- 
tremities oftenest  attacked,  while  Gerhardt,  in  his  collected  cases, 
found  the  larger  joints  of  the  upper  entremity  most  liable.'' 

Nolen  5  collected,  out  of  literature,  118  cases  of  gonorrhoea!  joint 
affections  (iii  men  and  7  women),  which  affected  308  joints,  in  the 
following  relation:  knee,  86;  foot,  52;  shoulder,  29;  hand,  26; 
fingers  and  toes,  17;  metatarso-phalangeal,  16;  hip,  15;  elbow,  13, 
etc.  One  joint  alone  was  affected  21  times;  two  joints  were 
affected  12  times;  three  joints  w^ere  affected  12  times;  many  or  all 
joints  were  affected   15  times. 

ig)  MiscellancoiLS  Conditions.  —  In  tabes  dorsalis  (locomotor 
ataxia)  a  definite  pathological  condition  of  the  joints  is  clearly  rec- 
ognized. The  affection  is  known  as  Charcot's  disease  (having  been 
first  demonstrated  by  him),  spinal  arthropathy,  tabetic  arthropathy, 
etc. 

Arthropathy  of  the  same  type  occurs  also  in  acute  myelitis, 
hemiplegia,  disseminated  scleroses,  the  paralysis  of  Pott's  disease, 
progressive  muscular  atrophy,  in  certain  cases  of  tumors  occupying 
the  gray  substance  of  the  cord,  and  in  certain  traumatic  lesions  of 


■'  Petrone  :  Rivesta  Clinica,  1SS3,  No.  2;  Kammerer  :  Cent.  f.  Chir. ,  1SS4.  No.  4; 
Sonnenburg  :  Veroffentl.  der  Gesellsch.  f.  Heilk.,  Berlin,  1S86,  p.  52;  Petrone  :  Spallan- 
zani,  18S5,  X.  and  .\i. 

==  Re\nllout :    Gaz.  des  Hop.,  1S75-89. 

3  Thomas :    "  Ziemssen's  Hdbch.  der  Spec.  Path.,"  ii. ,  2. 

■»  Gesellsch.  f.  Innere  Med.,  July,  1SS6. 

s  Archiv  f.  klin.  Med.,  1882,  xxxii.,  p.  I20. 


246  ORTHOPEDIC  SURGERY. 

the  cord.  In  short,  it  may  occur  in  any  cord  lesion  which  involves 
the  cells  of  the  anterior  gray  cornua.' 

The  joint  affection  appears  generally  at  an  early  stage  of  the  cord 
affection.  The  swelling  of  the  joints  may  be  quite  large,  and  con- 
sists of  an  effusion  in  the  joint,  and  an  oedema  of  the  whole  limb. 
This  often  appears  suddenly,  and  may  subside,  in  part,  with  equal 
rapidity.  There  are,  of  course,  severe  and  milder  types.  In  the 
severe  cases,  the  synovial  membrane  is  pale  and  covered  with  gran- 
ulations, the  capsule  is  thickened  and  covered  by  a  deposit  of  lime, 
and  in  the  severest  cases  the  capsule  is  entirely  absorbed,  and  the 
ends  of  the  bone  are  distorted,  hypertrophied,  or  atrophied.  The 
effusion  is  rarely  purulent,  and  if  so,  it  is  due  to  violence.  Luxation 
and  spontaneous  fracture  may  occur.  The  affection  is,  by  Virchow 
and  others,  considered  to  be  due  to  predisposition  in  the  bones  to 
faulty  cellular  change,  resulting  from  the  nervous  disease  of  the 
spinal  cord ;  ^  though  others  regard  the  affection  as  due  to  the  im- 
pairment of  sensation  in  the  joint.  Injuries  which  would  ordinarily 
cause  pain  and  necessitate  rest  in  tabetic  individuals  do  not,  and 
the  resulting  and  repeated  inflammations  eventually  injure  the 
joint.  Pathologically,  the  morbid  changes  do  not  differ  greatly 
from  those  of  formative  ostitis  (arthritis  deformans),  except  that 
the  process  may  be  much  more  extensive.  The  clinical  course  is" 
ordinarily  chronic,  but  it  may  become  rapid  and  be  attended  by 
complete  disability  of  the  joint. 

The  affection  attacks  the  joints  in  the  following  frequency:  out 
of  107  cases,  the  knee  was  affected  78  times;  the  hip,  31  times;  the 
shoulder,  21  times;  the  tarsus,  13  times;  the  elbow,  10  times;  the 
ankle,  9  times;  the  wrist  and  jaw,  each  2  times,  and  the  spine  once. 

A.  Sydney  Roberts,^  in  a  paper  on  spinal  arthropathies,  deduces 
the  following  practical  facts :  First,  regarding  the  period  of  devel- 
opment. The  tabetic  arthopathies  may  occur  independently,  or 
precede  the  active  symptoms  of  locomotor  ataxia.  Then,  again, 
they  may  develop  suddenly,  late  in  the  course  of  a  posterior  spinal 
sclerosis. 

He  considers  that  the  peripheral  expression  of  central  nerve  irri- 
tations is  characterized  by  the  following  changes  found  in  the 
structures  of  the  various  articulations:  (i)  A  chronic  asthenic 
hyperaemia  of  the  synovial  membranes;  a  hydrarthrosis.  (2)  An 
interstitial  atrophy  of  the  epiphyses.     (3)  A  fungous  or  rarefying 

^Charcot:  Vol.  i.,  p.  121,  "Arthropathy  m  Progressive  Amyotrophy";  Mitchell: 
Am.  Jour.  Med.  Sciences;  Michaud  :  "  Sur  le  meningite  et  la  myelite  dans  le  mal  uest," 
Paris,  1871;  Gull:  Guy's  Reports,  1858;  "Arthropathy  in  Hemiplegia,"  Scott  Allison; 
Dann  :  Lancet,  ii.,  1831,  p.  235. 

^  Centralblatt  f.  Chir.,  October  15th,  1887;  ibid.,  No.  22,  3887;  ibid..  No.  25,1887,  p.  5. 

3  Phila.  Med.  Times,  Feb.  i8th,  1885. 


EriOLOGY,    KTC,    ()/■'   CIIKONJC  JOINT  /J/S/wlS/C.  247 

epiphyseal  liypcrtrophy.  (4)  The  formation  (A  osf,(.f)j)liytes  and 
bony  stalactites.  These  various  joint  expressions  characteristic  of 
spinal  arthropathies  naay  exist  separately,  but  are  usually  combined 
in  the  same  subject. 

They  may  readily  be  distinguished  from  the  common  inflamma- 
tory lesions  by  the  total  absence  of  the  reflex  neural  phenomena, 
that  is,  of  pain,  both  reflex  and  local,  the  apprehensive  state  re- 
garding joint-movements,  and  the  reflex  or  tetanic  spasm  of  the 
muscles,  always  associated  with  joint  arthritis.  There  is  some  dif- 
ficulty in  differentiating  the  affection  from  malignant  disease,  but 
a  careful  inquiry  into  the  history  and  course  of  the  lesion,  and  the 
presence  or  absence  of  central  disturbances,  are  our  most  reliable 
guides. 

The  progress  of  the  arthropathies  is  most  often  essentially  chronic. 
Occurring  not  infrequently  early  in  the  history  of  a  tabetic  lesion 
they  slowly  increase,  with  occasional  exacerbations,  and  years  elapse 
before  fully  matured. 

A  rapidly  developing  arthropathy  may  be  associated  with  the 
later  stages  of  an  ataxia.  Their  course  is  self-limiting,  though 
never  reparative. 

Hcsmophilia  is  another  condition  in  which  a  peculiar  and  charac- 
teristic joint-affection  is  occasionally  met ;  hemorrhage  from  the 
synovial  membrane  of  the  joints,  as  well  as  from  the  serous  mem- 
branes in  other  parts  of  the  body  is  found.  This  comes  on  either 
spontaneously  or  in  consequence  of  some  injury,  and  affects  most 
frequently  the  knee,  elbow,  and  ankle.  Fresh  dark  blood  is  poured 
out,  and  the  cartilage,  ligaments,  and  synovial  membrane  are  stained 
by  it,  and  the  cartilage  shows  a  tendency  to  degenerate.  Micro- 
scopical examination  of  the  cartilage  in  the  case  reported  by  'Wx. 
Legg,  showed  only  the  ordinary  early  changes  of  inflammation. 
All  the  changes  seem  purely  the  results  of  synovial  hemorrhage. 

Certain  pathological  conditions  do  not  easily  come  under  the 
heads  of  this  or  any  classification  and  must  be  considered  inde- 
pendently. 

Groiviiig  Pains. — A  joint  affection  incident  to  growth  has  been 
described  by  Bouilly,  and  has  long  been  known  but  unclassified  by 
practitioners,  and  popularly  considered  to  be  incident  to  growth 
— "  growing  pains."  There  is  slight  pain  chiefly  in  the  juxta-epiphy- 
seal  region,  most  commonly  near  the  lower  epiphysis  of  the  femur. 
This  pain  is  brought  on  by  fatigue,  strains,  or  exposure.  In  the 
lightest  cases  the  symptoms  pass  away  in  a  few  hours.  In  severer 
forms  they  may  last  for  several  days,  and  the  pain  be  accompanied 
by  slight  fever.  In  the  severest  form  the  affection  may  continue 
for  months.     There  may  be  slight  effusion  in  the  joints,  but  recov- 


248  ORTHOPEDIC  SURGERY. 

ery  eventually  takes  place.  It  may  occur  during  the  ages  between 
five  and  twenty-one/ 

A  great  amount  of  harm  is  done  in  referring  to  this  class  the 
pains  of  beginning  chronic  joint  disease.  Growing  pains  proper  are 
neither  severe  nor  permanent. 

Analogous  to  this  may  be  mentioned  what  has  been  termed  by 
French  writers  maladie  de  la  croissance — which  is  in  reality  a 
hyperaemia  and  sensitiveness  of  the  epiphysis  in  adolescents — anal- 
ogous to  what  is  seen  occasionally  in  rickets. 

Acute  Arthritis  in  Infants. — English  writers  have  described,  un- 
der the  term  of  acute  arthritis  in  infants,  a  form  of  acute  epiphy- 
sitis or  juxta-epiphysitis  occurring  in  infants  from  two  months  to 
two  years  of  age.  It  is  of  a  particularly  severe  form.  It  is  ex- 
tremely fatal,  death  occurring  in  13  out  of  27  cases.  Several  joints 
may  be  attacked.  The  knee,  hip,  and  shoulder  are  the  ones  most 
frequently  involved.  The  joint  at  first  is  stiff,  pain  and  swelling 
follow,  and  later  an  abscess  is  formed.  Out  of  27  cases,  the  hip 
was  attacked  14  times,  the  knee  11,  the  shoulder  5,  the  ankle  and 
elbow  4  times  each,  the  wrist  once.  Out  of  the  27  cases,  in  20  the 
affection  was  monarticular.- 

TJie  Distribution  of  CJironic  Joint  Disease. — Of  2,002  cases  of  all 
kinds  of  joint  disease  collected  ^  from  the  clinics  of  Volkmann,"* 
Langenbeck,^  Hueter,^  and  Socin,^  IjSS/  were  of  the  lower  extrem- 
ity, 615  of  the  upper. 

The  distribution  of  all  the  various  forms  among  the  special  joints 
was  as  follows:  knee,  711;  hip,  333;  foot,  234;  elbow,  183;  hand, 
172;  shpulder,  166;  finger,  94;  tarsus,  78;  toes,  31. 

Of  834  cases  collected  by  Schiiller,  showing  the  frequency  of  the 
various  kinds  of  joint  disease,  there  were  240  cases  (28.7  per  cent) 
of  acute  serous  synovitis;  26  cases  (3  per  cent)  of  acute  purulent 
synovitis;  67  cases  (8  per  cent)  of  simple  chronic  synovitis;  138 
cases  (16.3  per  cent)  of  arthritis  deformans;  343  cases  (43.5  per 
cent)  of  scrofulous  or  tuberculous  joint  disease.  Schiiller  estimates 
the  general  relation  of  acute  to  chronic  joint  disease  as  4  to  6  in 
general,  although  hospital  clinics  would  set  it  as  3  to  7,  because 
acute  joint  rheumatism  and  metastatic  inflammations  are  not  seen 
here. 

Two  or  more  joints  may  be  attacked  at  the  same  time,  not  infre- 

'  Gaz.  des  Hopitaux,  1883,  p.  1034. 

^  Ploward  Marsh  :    "  Diseases  of  Joints." 

3  Arch,  fiir  klin.  Chir. ,  xxi. ,  Berlin,  1877. 

4  Beitrage  zur  Chir.,  p.  152,  Leipzig,  1875. 

s  Jahresberichte  (i877-]884)  des  Spitales  zu  Basel. 

^  Hueter  :    "  Gelenkkrankheiten,"  i.,  164. 

7  Schiiller  :    "  Die  Path.  u.  Ther.  der  Gelenkentzlindungen,"  p.  33. 


ETIOLOGY,   ETC.,    ()/■'   CHRONIC  JO  J  N'J'  DISEASE.  249 

quently  in  the  affection  known  as  chronic  rheumatoid  artlirilis,  but 
also  in  tuberculous  diseases. 

Course  and  Termination. — The  clinical  course  of  the  different  dis- 
eases of  the  joints,  while  varying  somewhat  according  to  the  ana- 
tomical surroundings  of  the  different  articulations,  preserves  the 
types  sufificiently,  so  that  a  description  of  the  disease  in  one  joint 
will  serve  for  that  of  another  within  certain  limits.  Tlie  ?jest  type 
of  a  serous  joint  effusion  will  be  found  in  effusion  of  the  knee-joint, 
while  for  typical  tubercular  ostitis  of  the  joints,  the  history  of  the 
larger  joints,  hip  or  knee,  will  serve ;  and  the  same  is  true  of  chronic 
rheumatoid  arthritis.  It  will  therefore  be  simpler  to  describe  the 
clinical  course  of  the  affections  of  the  joints  under  the  heads  of  the 
special  joints. 

Joint  affections  terminate  either  in, a  cure  with  more  or  less  perfect 
motion  of  the  articulation,  or  in  destruction  of  the  joint  with  a 
resulting  deformity  or  loss  of  the  limb,  or  in  ankylosis.  Synovitis, 
whether  serous  or  purulent,  is  a  much  less  destructive  affection  than 
ostitis  and  follows  a  milder  course.  Its  results  are  therefore  much 
more  favorable. 

Chronic  serous  synovitis  is  chiefly  harmful  in  its  weakening  action 
upon  the  articulations  which  it  affects.  The  lateral  ligaments  of 
the  knee  loosen  and  lateral  motion  may  be  present  in  the  joint. 
Added  to  this  is  a  loss  of  control  over  the  joint  motions  and  a 
constant  feeling  of  insecurity  on  the  part  of  the  patient.  This 
may  lead  to  almost  complete  disability  of  the  joint. 

Chronic  purulent  synovitis  is  more  destructive,  although  it  may 
resolve  and  leave  unimpaired  motion;  but  more  commonly  motion 
in  the  affected  joint  is  ultimately  restricted  and  complete  ankylosis 
results  at  other  times. 

Epiphyseal  ostitis,  again,  may  be  cured  Avith  perfect  restoration 
of  joint  motion,  but  these  cases  are  exceptional  and  more  commonly 
one  must  expect  decided  impairment  of  motion  or  complete  anky- 
losis, or  on  the  other  hand  the  process  may  never  reach  so  desira- 
ble a  state  as  ankyolsis,  but  it  may  go  on  to  disintegration  of  the 
joint  or  almost  endless  suppuration.  The  impairment  of  motion 
comes  oftenest  from  the  formation  of  adhesions  which  represent 
the  organization  into  connective  tissue  of  the  morbid  products 
present  in  the  joint  during  the  disease.  Cure  with  perfect  motion 
may  result  even  after  joint  abscess  has  occurred,  but  as  a  rule  any 
destruction  of  the  articulating  surfaces  results  in  restricted  motion. 

In  the  less  favorable  cases  destruction  of  the  joint  is  likely  to 
occur  in  tuberculous  ostitis  of  all  kinds  if  the  process  is  not 
checked.  All  the  tissues  of  the  joint  may  be'come  involved  and 
destroyed,  and  the  periarticular  tissues  may  be  invaded.      From 


250 


ORTHOPEDIC  SURGERY. 


this  stage  of  pan-arthritis  any  degree  of  destructive  change  can 
easily  result.  Dislocation  of  the  bones  and  disortion  of  the  limbs 
develop,,  the  tissue  about  the  joint  becomes  brawny  and  infil- 
trated, the  purulent  process  extends  up  and  down  in  the  shafts 
of  the  long  bones  as  an  osteomyelitis,  the  limb  becomes  oedema- 
tous  from  obstructed  and  diseased  blood-vessels,  and  operative  in- 
terference is  demanded.  Under  proper  treatment  in  by  far  the 
greater  number  of  cases  the  affected  joints  will  not  reach  the  con- 
dition just  described. 

In  certain  cases,  however,  the  disease  is  not  checked  by  treat- 
ment. 

With  so  grave  a  local  condition  as  is  seen  in  the  severest  forms 
of  joint  affections  the  general  system  does  not  escape  serious  im- 
pairment. Amyloid  degeneration  of  the  liver  and  other  viscera  at 
times  accompanies  this  condition  of  prolonged  suppuration,  it  is 
not,  however,  a  v^xy  common  affection.  Septicaemic  changes,  such 
as  cloudy  swelling  of  the  viscera,  phthisis,  tubercular  meningitis, 
etc.,  arc  other  consequences  of  long-continued  suppuration,  and 
frequently  follow  the  graver  forms  of  the  disease. 

Ankylosis  is  the  last  termination  of  serious  joint  disease  to  be 
considered. 

The  loss  of  mobility  may  vary  from  a  small  diminution  in  arc  of 
motion  to  a  complete  obliteration  of  all  movement.  Some  of  the 
pathological  processes  that  we  have  considered  are  perfectly  capa- 
ble of  destroying  the  articular  surfaces  and  replacing  them  by 
granulations.  The  granulations  in  turn  are  replaced  by  connective 
tissue  "  organized  "  directly  from  the  granulation  tissue.  Conse- 
quently it  is  easy  to  see  how  fibrous  bands  of  greater  or  less  extent 
are  formed,  running  from  one  bone  surface  to  the  other,  and  these 
in  turn  may  ossify  and  a  solid  bony  mass  may  be  formed  \vhere 
there  was  at  one  time  a  joint.  Oftener  fibrous  and  bony  ankyloses 
are  found  associated  with  each  other.  In  the  form  of  synovitis 
characterized  by  a  small  fibrinous  exudation  (dry  synovitis)  the 
formation  of  fibrous  bands  between  the  joint  surfaces  is  accom- 
plished  without  the  intervention  of  granulation  tissue. 

Other  causes  of  the  loss  of  motion  in  joints,  besides  fibrous  and 
osseous  ankylosis  of  the  joint  surfaces,  are:  i,  cicatricial  contrac- 
tion of  the  articular  capsule  and  ligaments;  2,  adhesions  between 
the  folds  of  the  synovial  sac  causing  restriction  of  joint  motion, 
and  secondarily  degeneration  of  the  cartilages,  in  consequence  of 
inaction;  3,  the  buttress-like  osteophytes  in  formative  ostitis;  and 
4,  in  pathological  luxations,  the  result  of  destructive  bone  inflam- 
mation causing  loss'  of  substance  in  the  ends  of  the  bones,  and  con- 
sequent malposition  of  the  articular  ends  of  the  bones. 


ETIOLOGY,   ETC.,    ()/■'   CIIKONJC  JO/NT  JJ/SEylSE.  351 

Bony  ankylosis  is  of  course  oftcncst  tlic  result  of  supimrative  syn- 
ovitis primary  or  secondary,  hut  not  necessarily  the  result;  for,  of 
thirty-five  cases  of  hip-joint  disease  analyzed  with  reference  to  the 
ultimate  amount  of  motion  in  the  joint  in  suppurative  and  non- 
suppurative cases,  it  was  found  that  the  presence  or  absence  of  ab- 
scesses had  no  effect  upon  the  ultimate  amount  of  motion  left  to 
the  joint.'  Marsh  found  bony  ankylosis  present  in  an  ankle-joint 
one  month  after  suppuration  began. 

On  the  other  hand,  as  we  have  seen,  true  bony  anchylosis  may 
occur  without  suppuration  at  all. 

But  as  a  rule  bony  ankylosis  is  only  present  after  the  disease 
has  been  quiescent  for  years.  And  many  errors  of  treatment  are 
made  by  assuming  that  it  has  taken  place  within  a  short  time  of 
the  cessation  of  the  disease. 

Treatment. — On  the  subject  of  treatment  of  chronic  diseases  of 
the  joints,  it  may  be  said  that  in  cases  influenced  by  constitutional 
states,  such  as  tuberculosis,  syphilis,  gout,  or  rheumatism,  constitu- 
tional treatment  is  manifestly  indicated.  It  is  self-evident  that  the 
better  the  patient's  health  is,  the  better  the  chances  of  recovery, 
even  in  affections  comparatively  localized.  In  tuberculous  joint 
affections  the  benefit  of  fresh  air  and  exercise  is  particularly  to  be 
borne  in  mind. 

The  general  methods  for  surgical  and  local  treatment  of  chronic 
diseases  of  joints  may  be  enumerated  as  follows:  i,  local  applica- 
tions (counter-irritation,  cauterization,  inunctions,  frictions,  mas- 
sage, subcutaneous  injections);  2,  compression;  3,  fixation;  4,  pro- 
tection from  jar;  5,  traction  (extension).  In  addition  to  these  the 
operative  measures,  aspiration,  incision,  excision,  and  amputation, 
are  needed  at  times. 

Local  Applications. — The  benefit  to  be  derived  from  local  applica- 
tions comes  chiefly  from  an  alteration  in  the  circulation  of  the 
parts  and  a  relief  of  a  condition  of  congestion,  if  such  exist.  Blis- 
ters, counter-irritation,  and  cauterization  play  less  of  a  part  in 
modern  therapeutics  than  formerly,  but  in  certain  cases  they  ap- 
pear to  afford  relief. 

Friction  and  massage,  apparently,  in  improving  the  circulation, 
improve  the  condition  of  the  joint  in  certain  cases.  It  is  probable 
that  in  this  way  galvanism  is  beneficial. 

Ignipuncture  in  joint  affections  has  been  recently  recommended 
by  Kolomin,  for  epiphyseal  ostitis,  especially  in  the  foot  and  wrist 
in  children.  In  cases  of  chronic  synovitis  with  absence  of  pain  and 
tenderness,  it  is  not  recommended  by  the  advocate  of  the  method. 

'New  York  Medical  Journal,  May  21st,   1S87  :    "Ultimate  Results   of    Mechanical 
Treatment  of  Hip  Disease." 


252 


ORTHOPEDIC  SURGERY. 


An  anaesthetic  should  be  used,  and  a  Paquelin  cautery  should  be  the 
instrument  employed,  and  either  superficial  punctures,  burning  the 
soft  infiltrated  tissues  round  the  joint,  can  be  made,  or  deep  punc- 
tures extending  to  the  bone  and  marrow,  the  latter  after  trephin- 
ing the  sound  bone.  Antiseptic  dressings  should  be  applied. 
Either  a  number  of  punctures  can  be  employed,  or  a  few  deep  ones, 
according  to  the  condition  of  the  disease.'  The  method  has  also 
been  used  by  Oilier,  who  divides  the  skin  and  sound  tissues  with  a 
knife,  and  if  necessary  the  bone  should  be  exposed  and  thorough 
antiseptic  cleansing  should  be  carried  out.  Oilier  and  Vincent  re- 
gard the  method  of  more  use  in  certain  diffuse  cases  of  tubercular 
epiphysitis  than  the  curette.'' 

The  benefit  of  inunctions  is  probably  that  of  frictions  generally, 
namely,  the  establishment  of  an  improvement  in  circulation  and 
the  diminution  of  congestion.  The  application  of  moist  heat,  as 
poultices  or  the  wet-pack,  is  often  agreeable.  And  if  there  is  in- 
flammatory heat  in  the  part,  cold  compresses,  irrigation,  or  the 
ice-bag  are  advantageous. 

The  subcutaneous  injection  of  solutions  of  iodoform  into  tuber- 
cular granulation  tissue  has  been  recommended  in  fungous  diseases 
of  joints,  but  the  results  reported  have  not  brought  the  method 
beyond  the  experimental  stage.  In  the  view  of  imitating  the 
spontaneous  cure  of  fungous  granulations  in  tuberculous  joint  dis- 
ease by  calcification,  Kolischer  has  in  a  number  of  cases  injected 
subcutaneously  a  concentrated  solution  of  calcium  phosphate  at 
the  seat  of  the  disease.  The  solution  is  as  follows:  75  grains  of 
neutral  phosphate  of  calcium  are  dissolved  in  twelve  ounces  of 
water,  and  enough  phosphoric  acid  is  added  until  a  perfect  solution 
is  obtained.  Nine  minims  of  dilute  phosphoric  acid  (Austrian 
Pharmacopoeia)  are  added  with  3  ounces  more  of  water.  The 
whole  solution  is  sterilized  by  boiling  and  injected  into  the  fungous 
tissue  by  means  of  a  syringe  with  a  platinum  needle.  The  joint  is 
dressed  with  gauze  wet  in  a  solution  like  the  above,  except  that  90 
minims  more  of  dilute  phosphoric  acid  should  be  added.  There  is 
a  great  deal  of  pain  after  the  injection  and  morphia  is  usually  nec- 
essary. Fever  and  induration  of  the  tissues  follows.  Kolischer 
reports  successful  cases.^ 

The  injection  of  solutions  of  iodine  into  the  joint  cavity  is  a 
remedy  formerly  occasionally  used,  which  fell  into  disuse. 

Of  late  the  irrigation  of  joints  with  aseptic  solutions  has  been 
advised  and  practised.     Solutions  of  carbolic  acid,  i   to  20,  or  of 

^  See  Boston  Medical  and  Surgical  Journal,  April  26th,  1883,  p.  392. 
^Vincent :  "Arthrotomie  Ignee."     Revue  de  Chirurgie,  January  loth,  1884. 
3  Wien.  Med.  Presse,  No.  22,  1887. 


ETIOLOGY,   ETC.,    OF   CHRONIC  JOINT  DISEASE.  253 

corrosive  sublimate,  i  to  1,000,  are  used.  Jla^^er  rejjorts  the  injec- 
tion through  a  small  trocar  of  such  stjlutions  with  benefit  in  cases 
of  relaxation  of  the  shoulder  and  of  the  temporo-maxillary  joint.' 

Coinprcssio)i. — Compression  promotes  absorption  of  fluid  in  fedc- 
matous  tissues  and  effusion.  It  can  most  readily  be  applied  to  the 
knee  by  means  of  rubber  bandages  or  other  elastic  compresses. 

Dried  compressed  sponges  bandaged  around  a  knee  and  then  wet, 
will,  by  expansion,  produce  pressure  in  cases  of  chronic  synovitis. 

Fixation. — Fixation,  i.e.,  the  prevention  of  motion  at  a  joint,  is 
indicated  in  all  active  inflammatory  conditions  of  a  joint.  In  sub- 
acute conditions  of  inflammation  a  limited  amount  of  careful 
motion  is  not  injurious,  the  amount  of  motion  varying  according 
to  the  state  of  the  joint.  Sudden,  violent,  or  jerky  motion  is,  how- 
ever, injurious. 

Verneuil  has  called  attention  to  the  danger  of  too  frequent  and 
early  use  of  forcible  passive  motion,  and  has  laid  great  stress  on 
the  undue  fear  of  the  formation  of  ankylosis  (ankylophobia,  as  he 
terms  it)  from  fixation  of  the  limb.  He  claims  that  ankylosis 
results  from  inflammation,  and  that  the  best  way  to  prevent  anky- 
losis is  to  check  inflammation,  most  readily  done  by  rest  and  fixa- 
tion; that  ankylosis  does  not  invariably  take  place  simply  from 
rest,  as  in  the  limbs  of  hemiplegics,  wdiere  immobility  is  unavoid- 
able. Ankylosis  does  not  result,  except  when  chronic  rheumatic 
arthritis  is  combined;  but  in  the  joints  stiffness  results  after  too 
long  fixation  in  fractures,  partly  from  traumatic  inflammation, 
partly  from  periarticular  contraction. - 

Protection. — Protection  from  the  jar  incidental  to  locomotion  is 
of  importance  in  ostitis  of  the  joints  of  the  lower  extremities, 
except  in  the  latest  stage  of  convalescence.  The  importance  of 
protection  is  often  overlooked  in  the  supposition  that,  if  a  knee  or 
ankle  is  fixed  by  a  stiff  bandage,  the  patient  can  bear  weight  upon 
the  limb,  forgetting  that  in  an  ostitis  jar  to  the  inflamed  epiphyses 
is  more  injurious  even  than  motion.  The  simplest  method  of 
protection  in  affections  of  the  lower  extremity  is  by  the  use  of 
crutches,  but,  as  will  be  seen  under  the  headings  of  individual  joints, 
other  more  convenient  means  can  be  used.  Protection  from  jar  in 
joints  of  the  upper  extremity  is  readily  effected  by  the  means  used 
for  fixation. 

Traction. — The  "traction  "  of  the  bones  forming  a  joint,  that  is, 
the  pulling  them  apart,  is  manifestly  desirable  when  the  inflamed 
epiphyses  are  being  crowded  together,  either  by  jar  or  muscular 
pressure.     Exaggerated  pressure  of  two  inflamed  bony  surfaces  of 

'  American  Journal  of  the  Medical  Sciences,  April,  iSSS. 
^  MouUin  :  "  Sprains,"  p.  116,  London,  1SS7. 


254  ORTHOPEDIC  SURGERY. 

a  joint  upon  each  other  increases  the  danger  of  necrosis,  and  the 
extent  of  the  destructive  ostitis,  by  diminishing  from  pressure  the 
blood-supply  proper  to  the  separation  of  the  inflamed  parts,  and 
by  thus  retarding  the  development  of  the  formative  or  cicatricial 
ostitis  from  which  a  cure  is  to  be  expected.  In  certain  joints,  as 
the  elbow,  sacro-iliac,  symphysis  pubis,  traction  is  impracticable. 
In  pure  synovitis,  where  there  is  no  danger  of  extension  to  the 
bone,  there  is  little  need  of  traction.  This,  however,  is  a  rare  con- 
dition in  the  larger  joints,  if  extensively  inflamed. 

The  operative  procedures,  aspiration,  arthrectomy,  and  arthro- 
tomy  will  be  considered  severally  under  the  headings  of  each  joint, 
where  they  are  to  be  borne  in  mind  as  therapeutic  methods. 

The  employment  of  these  several  methods  varies  not  only  in  the 
different  affections  of  the  joints,  but  also  in  the  different  joints,  for 
the  anatomical  conditions  vary  so  widely.  It  will,  therefore,  be 
necessary  to  leave  any  more  detailed  consideration  of  the  subject 
until  speaking  of  the  separate  joints. 


CHAPTER    VI. 

HIP    DISEASE. 

Definition.— Pathology.— Clinical  History.— Diagnosis.— Differential    Diag- 
nosis.— Prognosis. — Treatment  (Conservative — Operative;. 

The  affection  which  is  commonly  known  as  Hip  Disease  is  by 
far  the  most  frequent  affection  of  the  hij^  joint,  and  by  common 
usage  the  general  nam.e  of  "  Hip  Disease  "  or  "  Hip^joint  Disease  '"' 
has  become  limited  to  that  especial  affection  of  the  joint  which 
comes  now  for  consideration.  It  is  known  also  by  the  names  of 
morbus  coxarius  or  morbus  coxse,  coxalgia,  chronic  articular  ostitis 
of  the  hip,  and  coxo-tuberculose  (Lannelongue).  The  pathological 
condition  most  commonly  found  is  a  chronic  tuberculous  ostitis  of 
the  epiphysis  of  the  head  of  the  femur. 

Pathology. 

The  pathology  of  hip  disease  has  already  been  considered  in  its 
general  aspect  along  with  the  other  forms  of  tuberculous  joint  dis- 
ease in  Chapter  IV.  It  will  be  remembered  that  it  was  then  dem- 
onstrated that  the  affection  begins  most  often  as  an  ostitis,  and 
that  hip  disease  originates  as  a  synovitis  rarely.  The  point  of 
original  disease  has  been  by  various  writers  believed  to  be  in  the 
synovial  membrane,  the  ligamentum  teres  and  other  ligaments,  the 
cartilages,  and  even  the  subsynovial  tissue,  and  at  the  present  time 
authors  are  not  quite  agreed  as  to  the  most  common  initial  site  of 
the  affection.  It  is  not  worth  Avhile  to  catalogue  the  views  of 
various  authors;  but  it  may  be  briefly  stated  that  the  evidence  is 
strongly  in  favor  of  the  osseous  origin  of  the  disease  in  children, 
while  in  adults  an  initial  synovitis  is  more  common. 

Among  the  surgeons  who  hold  this  view  are  Bryant  (who  esti- 
mated nine-tenths  in  children  as  osseous  in  origin),  Barwell,  Rust, 
Gross,  Marsh,  Annandale,  Konig,  Volkmann,  Gibney,  and  Lanne- 
longue ;  but  Sayre,  Billroth,  and  others  favor  the  theory  of  a  syno- 
vial origin ;  and  one  still  finds  advocates  of  the  ligamentous  origin 
of  the  disease  in  Owen,  Holmes,  Adams,  and  Coulson. 


256 


ORTHOPEDIC  SURGERY. 


Miiller'  analyzed  the  specimens  of  61  hip  excisions,  and  found 
that  the  disease  began  in  the  bone  in  47  cases,  in  the  synovial  mem- 
brane in  3,  while  in  1 1  it  was  impossible  to  state  where  it  originated, 
Konig  investigated  with  regard  to  this  71  preparations  from  all  the 
joints  and  found  47  of  osseous  origin.''  Wright  bases  his  opinion 
upon  100  excisions  of  his  own  and  the  examination  of  specimens 
removed  by  other  surgeons,  and  believes  "  that  in  true  chronic 
morbus  coxae,  such  as  we  ordinarily  see,  and  also  in  the  acute  and 
rapidly  destructive  cases,  the  disease  begins  almost  invariably  in 
the  bone."  ^ 

There  are  certain  early  autopsies  which  have  showed  the  matter 
very  plainly;  one  was  the  case  mentioned  by  Gibney  in  his  book 
on  diseases  of  the  hip,  where  both  joints  were  affected;   and  in  one 

case  the  focus  was  in  the  head  of  the 
femur,  and  in  the  other  in  the  acetab- 
ulum. Lannelongue  has  reported  four 
early  autopsies;  but  autopsies  early 
enough  to  reveal  the  primary  condition 
are  not  common. 

Although  in  most  cases  the  head  of 
the  femur  is  the  primary  seat  of  dis- 
ease, there  is  no  question  that  in  others 
the  floor  of  the  acetabulum  is  first 
affected,  while  in  still  others  the  acetab- 
ulum becomes  involved  in  the  progress 
of  the  disease.  In  Wright's  100  cases 
the  acetabulum  was  necrosed  or  per- 
forated in  27,  in  14  of  which  there 
seemed  reason  to  believe  that  the  fe- 
FiG.  254.— Acetabular  Coxitis.  mur   was  first   affcctcd.       In  49  other 

cases,  however,  the  acetabulum  was  superficially  diseased. 

Habern  has  asserted  that  primary  acetabular  hip  disease  is 
much  more  common  than  has  been  supposed,  and  he  supports  his 
views  by  the  following  analysis  of  132  hip  resections  from  Volk- 
mann's  clinic* 

In  50  of  these  a  caseous  focus  of  the  acetabulum  was  found  with 
a  sequestrum  in  31 ;  in  23  there  was  a  focus  in  the  femoral  head, 
neck,  or  trochanter;  in  7  there  were  such  foci  in  both  acetabulum 
and  femur;  and  in  29  cases  the  disease  was  so  far  advanced  that  it 
was  not  possible  to  find  the  primary  focus  of  disease.     In  23  cases 


'  Konig- :    "  Die  Tuberc.  der  Knochen  and  Gelenke,"  Berlin,  iS 
=  Konig  :  Deutsch.  Z.  f.  Chir.  xi.,  1879. 

3  G.  A.  Wright :    "  Hip  Dis.  in  Childhood,"  p.  17. 

4  Cent.  f.  Chir.,  April  2d,  1881. 


////'    D/SKASE. 


257 


the  disease  appeared  to  have  hccii  jjiiinnrily  synovial.  J^eyorid 
this  there  is  really  no  definite  infonnation  to  he  given,  the  experi- 
ence of  all  operators  being  largely  the  same,  namely,  that  in  a  few 
cases  the  acetabulum  presents  evidence  of  having  been  primarily 
diseased,  but  that  in  a  greater  number  it  becomes  secondarily  af- 
fected in  the  course  of  the  disease  which  has  begun  in  the  head  of 
the  femur. 

When  once  the  acetabulum  has  become  diseased,  a  curious  en- 
largement of  it  is  apt  to  take  place.  The  irritated  pelvic  femoral 
muscles  which  are  in  a  state  of  tonic  contraction  crowd  the  head  of 
the  femur  against  the  upper  border  of  the  acetabulum  ;  under  this 
continual  pressure  absorption  of  that  jDortion  of  the  rim  of  the 
acetabular  cavity  takes  place  with  an  actual  enlargement  of  the 
cavity  from  below  upward.     This  enlargement   is  shown   in   the  ac- 


FlG.  255. 


Erosion  of  the  Head  of  the  Femur. 


Fig.  256. 


companying  figure.  This  so-callfd  migration  of  the  acetabulum  is 
the  cause  of  shortening  of  the  limb,  in  many  cases,  and  measure- 
ment will  show  that  the  trochanter  lies  above  Nelaton's  line. 

The  changes  in  the  head  of  the  femur  are  chiefly  the  result  of 
ostitis  and  pressure.  There  is  alteration  in  the  shape  of  the  head 
of  the  bone,  inasmuch  as  it  is  worn  away  by  the  pressure  induced  by 
constant  muscular  spasm  and  destruction  of  the  articular  surface. 
The  appearance  of  the  cartilage,  as  described  under  the  pathology 
of  that  structure,  often  suggests  ulceration,  and  hence  arose  the 
theory  that  the  original  seat  of  hip  disease  was  to  be  found  in  the 
cartilage.  There  are  cases  which  show  that  in  an  early  condition 
there  may  be  hyperaemia  and  ulceration  of  the  ligamentum  teres ; 
such  a  case  is  figured  by  Homes  in  his  "  Surgical  Diseases  of  Chil- 
dren," and  other  instances  are  reported  by  Martin  and  Collineau. 
The  condition  may  be  due  to  a  primary  tuberculosis  at  this  point, 
but  the  cases  cited  do  not  demonstrate  the  fact  conclusively,  and 
it  is  more  likely  that  ulceration  of  the  ligament  in  hip  disease  exists 
17 


258 


ORTHOPEDIC  SURGERY. 


either  as  an  extension  of  the  disease  from  the  epiphysis  or  secon- 
darily to  the  ostitis  and  contiguous  synovitis,  as  is  the  case  with  the 
crucial  ligament  at  the  knee  joint  in  disease  of  that  joint. 

"  Dislocation  "  of  the  hip  in  hip  disease  is  a  term  often  used 
which  is,  perhaps,  misleading.  True  dislocation  very  rarely  occurs, 
but  partial  destruction  of  the  softened  head  of  the  femur  in  the 
manner  just  described  leads  to  a  shortening  of  the  limb  and  to  an 
elevation  of  the  trochanter  above  its  proper  level.  The  wearing 
away  of  the  acetabulum  produces  the  same  result  and  both  these 
deformities  occur ;  but  true  dislocation  is  rare,  because,  even  if  the 
head  of  the  bone  is  almost  entirely  destroyed,  there  is  so  much  in- 


FiG.  257. — Diffuse  Epiphyseal  Ostitis, 


Fig.  258. — Pathologically  Enlarged  Acetabulum. 


flammatory  tissue  deposited  about  the  joint  that  the  head  of  the 
bone  is  retained  partly  in  place. 

Fracture  of  the  atrophied  and  degenerated  shaft  of  the  femur 
may  occur  in  occasional  cases. 

A  typical  specimen  from  a  fairly  advanced  case  of  hip  disease 
shows  a  reddened  and  thickened  synovial  membrane,  perhaps  even 
broken  down  into  granulations  ;  the  cartilage  is  gone  from  the  head 
of  the  femur  or  hangs  in  tags  or  shreds,  and  the  general  appearance 
of  the  end  is  often  spoken  of  as  "  worm  eaten,"  a  term  which  de- 
scribes it  very  well ;  and  sometimes  the  whole  cartilage  may  be 
lifted  from  the  bone  by  a  layer  of  granulations.  The  epiphyseal 
portion  of  the  head  of  the  femur  has  probably  disappeared  in  part 
or  altogether,  and  a  ragged,  carious  end  of  bone  will  articulate 
with  the  acetabulum  if  the  cartilage  has  entirely  disappeared. 

Much  importance  has  been  attached  lo  the  presence  of  sequestra 


////'    niShlASI'l. 


259 


in  the  diseased  bone.  Tin:  wliolc  epipliysis  may  form  one  seques- 
turm,  but  this  is  not  common.  Sometimes  a  sequestrum  hes  in 
the  epiphysis,  but  more  connnonly  it  extends  on  bf^th  sides  of  the 
epiphyseal  line;  while  sometimes  tlie  dead  bone  extends  some  little 
distance  into  the  diai)hysis. 

The  acetabulum  at  this  same  stage  is  generrdly  lined  with  <(ranu- 
lation  tissue;  the  cartilage,  wln'ch  may  be  large  in  amount,  has  either 
disappeared  or  it  is  rough  and  eroded.  Perforation  of  the  floor  of 
the  acetabulum  may  take  place,  but  this  generally  is  to  be  seen 
only  in  advanced  cases  of  hip  disease.  Inside  of  the  pelvis  a  dense 
wall  of  fibrous  tissue  and  thickened  periosteum  shuts  off  the  head 
of  the  femur  or  the  contents  of  the  joint  from  the  pelvic  cavity. 
In  cases  where  the  disease  has  gone  on  as  far  as  this,  extensive  dis- 
ease of  the  pelvic  bones  is  likely  to  coexist.  In  the  other  direction, 
when  once  the  disease  of  the  femur  has  passed  the  epiphyseal  line, 
there  is  no  limit  to  be  set  to  its  course  or  its  extent  of  destruction. 

Abscesses  appear  externally  if  the  disease  of  the  joints  extends 
to  the  peri-articular  tissues,  or  where  a  separate  focus  of  disease 
formed  outside  of  the  joint  spreads  to  the  surrounding  soft  parts. 

Suppuration  inside  of  the  pelvis  is  not  a  very  uncommon  condi- 
tion in  the  acetabular  form  of  the  disease-^in  the  femoral  form  it 
only  accompanies  advanced  disease.  It  arises  most  commonly 
from  perforation  of  the  acetabulum  or  from  inflammation  inside 
the  pelvis  excited  by  the  bone  disease  in  the  neighborhood ;  or 
again  the  pus  may  ascend  to  the  brim  of  the  pelvis,  either  in  the 
sheath  of  the  psoas  muscle  or  in  other  tissues  and  then  gravitate 
down  the  inner  wall.' 

A  natural  cure  results  in  one  of  twow^ays:  by  the  absorption 
or  calcification  of  the  tuberculous  tissue  at  an  early  or  a  late  stage 
of  the  disease ;  or  by  the  purulent  degeneration  of  such  tissue  and 
its  evacuation  by  an  external  opening  and  discharge.  But  a  spon- 
taneous cure  is  not  the  natural  tendency  of  the  disease  in  the  early 
stages.  The  suppuration  which  comes  later  seems  to  be  nature's 
effort  to  eliminate  the  diseased  material,  and  it  is  the  common 
method  by  which  spontaneous  cure  results  when  it  does  occur. 
This  late  stage  of  the  disease  is  not  likeh-  to  have  resulted  until 
malpositions  and  shortening  of  the  limb  have  come  on  and  much 
impairment  of  the  general  condition  has  resulted.  It  is  this  state 
of  affairs  that  makes  the  spontaneous  cure  of  hip  disease  unlikely 
and  imperfect. 

When  spontaneous  cure  does  occur  it  is  almost  invariably  with 
an  ankylosed  joint.  The  articular  surfaces  have  been  destroyed  by 
the  disease  and  being  melted  into  pus  have  been  carried  away  and, 
'  R.  W.  Parker:    Chir.  Soc.  Trans.,  iSSo. 


26o  ORTHOPEDIC  SURGERY. 

in  part  of  the  joint  at  least,  eroded  and  hyperaemic  bone  surfaces 
are  in  contact,  and  motion  between  these  would  be  impossible. 
At  first,  these  are  connected  together  by  the  organized  granulation 
tissue,  which  solidifies  into  tough  fibrous  tissue  which  in  turn  be- 
comes the  seat  of  the  deposit  of  lime  salts,  and  a  solid  mass  of  bone 
exists  where  once  there  was  a  joint. 

In  these  cases,  however,  one  sometimes  finds  at  autopsy  an  in- 
cluded cheesy  focus  which  still  presents  some  signs  of  activity.  It 
is  to  these  foci  that  one  looks  for  an  explanation  of  the  late  relapses 
of  the  disease  and  the  very  great  harm  which  is  sometimes  done 
by  forcible  manipulation  of  these  joints  and  consequent  relighting 
of  the  original  tuberculous  disease.  In  a  case  of  cured  hip  disease 
under  the  writers'  observation,  where  there  had  been  ankylosis  and 
freedom  from  symptoms  for  some  years,  fatal  tetanus  suddenly 
developed  without  any  assignable  cause,  and  autopsy  showed  an 
ankylosed  hip  joint  in  which  was  included  a  large  tuberculous  focus 
which  was  the  only  peripheral  source  to  which  the  tetanus  could 
be  assigned.' 

Ifi  other  respects  the  pathology  of  hip  disease  has  been  described 
under  the  general  pathology  of  joint  disease. 

Clinical  History. 

Early  Symptoms. — The  beginning  of  the  affection  is  most  often 
gradual  and  insidious,  but  at  times  it  begins  so  abruptly,  according 
to  the  parents'  account,  as  to  suggest  a  traumatic  origin.  The 
child  will  be  noticed  to  limp  at  times  and  at  other  times  to  be  com- 
paratively free  from  lameness. 

This  lameness  increases,  and  it  will  be  found  that  the  patient  is 
inclined  to  strike  the  ball  of  the  foot  rather  than  the  heel  in  walk- 
ing; although  the  heel  can  be  put  down  to  the  floor,  yet  instinct- 
ively the  knee  is  slightly  bent  and  the  heel  raised  when  the  weight 
of  the  trunk  falls  on  the  hip.  There  is  a  certain  amount  of  stiff- 
ness of  gait  apparent  in  the  morning  when  the  patient  first  gets 
out  of  bed,  and  after  sitting  for  a  while;  this  passes  away  after  the 
patient  has  Avalked  or  played  about.  At  night,  as  a  rule,  the  limp 
is  less  than  in  the  morning.  The  limp  can,  perhaps,  best  be  de- 
scribed as  a  very  slight  stiffness  and  dragging  of  the  affected  leg  in 
walking. 

If  the  child  be  inspected  it  will  be  seen  that,  although  able  to 
run  about  and  play  freely,  there  is  a  noticeable  limp,  and  in  stand- 
ing the  knee  of  the  affected  side  is  usually  flexed  slightly,  the  pelvis 
being  tipped,  and  the  thigh  slightly  abducted.     The  tilting  of  the 

'  Trans.  American  Orthopedic  Association,  vol.  i. 


////'  i)1si:asi: 


261 


pelvis  and  abduction  of  the  tliii;li  may  he  so  slight  that  it  is  scarcely 
noticeable,  except  by  the  tleviation  from  the  median  line  of  the 
fold  between  the  two  buttocks.  In  girls  the  vulva  on  the  affected 
side  will  be  seen  to  be  lower  than  f)n  the  other  side. 

With  regard  to  pain  at  this  stage  it  is  very  often  absent  and  if 
present,  is  noted  as  night  cries,  to  which  allusion  will  be  made. 

It  has  been  customary  to  divide  hip  disease  into  stages  and  to 


Fig.  259. — Position  Assumed  in  Standing  with 
slight  Abduction  of  the  Right  Leg. 


Fig.  260. — Tilting  of  the  Pelvis  and  Abduction  of  the 
Thigh  in  Hip  Disease. 


ascribe  to  these  stages  certain  definite  symptoms.  There  is  little 
agreement  among  writers  on  the  subject  as  to  what  these  stages 
should  be,  and  from  a  clinical  and  pathological  standpoint  it  is  not 
desirable  to  attempt  any  such  division,  for  even  if  such  a  classifica- 
tion is  made,  it  is  hard  to  identify  the  stages  clinically  and  they  are 
often  so  ill-defined  that  much  confusion  results. 

In  the  early  part  of  the  disease,  pain  at  night,  stiffness,  and  limp- 
ing are  the  chief  symptoms.     Then  folloAv  malpositions  of  the  limb, 


262 


ORTHOPEDIC  SURGERY. 


more  severe  disability,  and  greater  pain  and  sensitiveness  perhaps. 
Abduction  of  the  diseased  limb  is  a  little  the  most  common  of  the 
malpositions  of  the  early  stage,  but  adduction  is  by  no  means  un- 
common as  an  early  symptom.  Later  in  the  course  of  the  affection 
adduction  is  much  more  frequent  than  abduction. 

Succeeding  the  deformities  which  have  just  been  described,  one 
finds  abscess  formation  and  the  development  of  sinuses;  and  this 
stage  of  the  affection  will  hardly  have  been  reached  without  con- 
siderable constitutional  deterioration,  which  may  become  extreme, 
and  in  a  few  cases  caused  death  by  amyloid  degeneration  of  the 
viscera. 

Lameness. — From  being  at  first  scarcely  perceptible,  the  lameness 
increases  and  the  limp  becomes  very  noticeable.    In  very  acute  cases, 


Fig.  261. 


The  Gait  in  Hip  Disease. 


Fig.  262. 


pain  may  become  so  severe  that  the  child  will  refuse  to  use  the  leg, 
or  malposition  of  the  leg  may  come  on  rapidly  and  the  limp  may  on 
that  account  become  excessive,  but  in  general  the  child  walks  with- 
out pain,  though  perhaps  limping  badly.  Until  the  very  late  stages 
of  the  disease  lameness  is  not  due  to  bone  shortening.  The  accom- 
panying figures  shows  the  appearance  presented  in  walking  by  a 
boy  with  a  fixed  and  sensitive  hip  joint. 

Pain. — As  the  affection  progresses,  pain  in  the  knee  and  sensi- 
tiveness to  jarring  the  limb  may  become  prominent  symptoms,  the 
pain  being  located  by  the  patient  in  the  knee  in  the  great  majority 
of  all  cases.  The  adductor  muscles  of  the  thigh  will  be  found  near 
the  symphysis  pubis  to  be  prominent  and  contracted,  and  frequently 
there  is  a  thickening;  of  the  tensor  vag-inae  femoris  noticeable  on 


////'  nisi'iASi'..  263 

palpation.  An  unconscious  prolcction  of  the  joint  will  be  noticed 
in  the  movement  of  the  patient,  the  focjt  of  the  well  limb  will  be 
placed  under  the  lower  part  of  the  other  le^  when  it  is  to  be  sud- 
denly lifted  by  the  p9.tient,  as  from  the  floor  to  the  bed,  or  from  the 
bed  to  the  floor,  or  in  moving  from  one  side  of  the  bed  to  the  other. 
In  walking,  the  patient  instinctively  avoids  resting  weight  upon  the 
limb,  except  for  as  short  a  time  and  with  as  little  jar  as  is  possible, 
the  thigh  being  slightly  flexed,  tlie  knee  being  bent,  and  the  heel 
raised  so  that  the  shock  upon  the  acetabulum  from  pressure  of  the 
head  of  the  femur  \whcn  the  weight  of  the  body  is  thrown  upon 
the  limb)  may  be  broken  at  the  knee  and  ankle  joints,  which  serve 
as  springs.  This  attitude  of  the  limb — flexion  of  the  thigh — be- 
comes habitual  and  characteristic ;  to  it  is  added  in  the  earlier  and 
more  acute  stages  adduction,  abduction,  and  outward  rotation  of 
the  limb. 

In  manipulating  the  leg  at  this  stage  pain  may  follow  the  slight- 
est jar  to  the  joint,  or,  on  the  other  hand,  the  joint  may  be  perfectly 
stiff  by  muscular  spasm  and  yet  manipulation  may  be  wholly  pain- 
less. In  other  cases  a  certain  arc  of  motion  can  be  described  with- 
out causing  pain,  but  when  the  limits  of  this  arc  are  reached,  fur- 
ther motion  becomes  painful  and  is  prevented  by  muscular  fixation. 
The  sensitiveness  of  the  joint  may  become  so  great,  when  an 
acute  stage  supervenes,  that  the  slightest  movement  of  the  patient, 
or  jar  of  the  bed  or  room,  causes  extreme  suffering.  The  limb 
is  flexed  at  the  thigh,  everted,  and  abducted.  This  stage  may 
come  suddenly  and  gradually  pass  away,  the  pain  diminishing  by 
degrees  under  the  enforced  treatment  of  rest,  or  it  may  be  pro- 
longed for  months.  The  patient  will  gradually  become  able  to 
move  the  limb,  or  steady  it  with  the  sound  limb  or  with  the  hands; 
a  characteristic  position  is  frequently  taken  by  the  patient,  who 
places  the  well  foot  on  the  dorsum  of  the  foot  of  the  affected  limb, 
exerting  pressure  away  from  the  acetabulum.  Pain  may  be  absent 
at  any  or  all  stages  of  the  disease,  and  is  not  a  diagnostic  sign  for 
or  against  the  presence  of  hip  disease ;  and  it  should  be  ah\'ays 
borne  in  mind  that  tenderness  or  sensitiveness  at  or  about  the  joint 
may  be  absent,  consequently  the  absence  of  these  symptoms  does 
not  indicate  the  absence  of  well-pronounced  disease.  The  joint 
may  be  firmly  held  by  muscular  spasm,  allowing  restricted  motion 
on  manipulation,  while  sensitiveness  may  be  absent,  upon  which, 
however,  at  any  time  a  sensitive  condition  of  the  joint  ma}*  super- 
vene. 

The  pain  is  often  remittent,  and  here,  as  in  all  the  symptoms  of 
this  affection,  the  most  marked  remissions  may  occur.  The  loca- 
tion of  the  pain  is  variable,  but  is  generally  referred  to  the  inside 


264  ORTHOPEDIC  SURGERY. 

and  front  of  the  thigh  near  the  knee  or  directly  at  the  knee  joint. 
The  intimate  relations  and  anastomoses  of  the  sciatic,  obturator, 
and  anterior  crural  nerves  seem  to  furnish  the  best  explanation  of 
this,  although  Bonnet  thought  it  due  to  the  position  of  the  pa- 
tient, lying  in  bed  with  the  leg  rolled  over  on  its  outer  side,  a  con- 
sequent strain  being  put  upon  the  external  lateral  ligaments. 

There  are  various  explanations  offered  beside  these,  one  of  which 
is  that  of  Dr.  Sayre,  to  the  effect  that  the  pain  is  a  result  of  the 
struggle  between  the  adductor  muscles  and  the  distended  capsule. 
The  causes  as  enumerated  by  Wright '  seem  to  explain  the  "re- 
flected "  pain  most  satisfactorily.  These  are,  first,  the  supply  of 
both  hip  and  knee  by  the  obturator,  sciatic,  and  anterior  crural 
nerves ;  second,  sympathy  between  the  ends  of  bones  or  direct  ex- 
tension of  the  inflammation  ;  third,  muscular  spasm. 

Attempts  have  been  made  to  differentiate  the  varieties  of  hip 
disease  by  the  location  of  the  pain,  but  little  or  no  reliance  can 
be  placed  upon  such  a  system.  Erichsen,  for  example,  believes 
that  pain  in  the  knee  is  most  marked  in  "  femoral  coxalgia,"  from 
stretching  of  the  obturator  nerve  over  an  abscess  or  from  its  being 
involved  in  the  thickened  tissues  about  the  femur.  Pain  in  the 
joint  he  interprets  as  "  arthritic  coxalgia,"  while  pain  in  the  iliac 
fossa  or  side  of  the  pelvis  would  mean  "acetabular  coxalgia." 

In  general  the  pain  is  referred  to  the  whole  front  of  the  lower 
thigh  or  to  the  inside  of  the  knee  over  the  inner  condyle.  In  a 
minority  of  cases  the  pain  is  referred  to  the  joint  itself.  In  the 
more  acute  cases  sensitiveness  to  pressure  on  the  trochanter  and 
to  any  manipulation  of  the  leg  is  present.  But  again  the  whole 
course  of  disease  may  be  gone  through  without  the  development 
of  local  tenderness. 

Night  Cries. — At  an  early  stage  of  the  affection  the  symptoms 
of  "  night  cries  "  often  appear.  They  occur  in  the  early  part  of 
the  night,  usually,  and  may  become  an  exceedingly  annoying  symp- 
tom. After  the  patient  is  asleep,  and  to  all  appearance  entirely 
unconscious,  sleep  will  be  interrupted  by  a  loud  cry  as  if  of  severe 
pain,  followed  by  moaning  or  crying  for  a  few  seconds ;  the  child 
being  unconscious  or  only  half  conscious  of  the  cause  of  the  pain. 
These  do  not  occur  when  the  patient  is  entirely  awake,  and  are 
caused  by  the  spasmodic  twitching  of  the  muscles  abnormally  irri- 
table from  irritation  reflex  to  the  inflammation  of  the  joint.  These 
cries  may  vary  from  a  short  moan  to  a  piercing  shriek,  and  may  in 
the  severest  cases  be  repeated  fifteen  or  twenty  times  during  the 
night.  They  do  not  occur  in  the  later  stages  of  the  disease,  and 
may  be  entirely  wanting  in  the  mildest  cases.  They  resemble 
'  G.  A.  Wright:    "  Hip  Disease  in  Childhood,"  p.  39. 


jiir  j)isi-:asi-:.  265 

somewhat  the  cry  in  the  "  ni'L^ht  terrors  "  of  nerv^ous  children,  but 
differ  from  those  in  tliat  there  is  greater  evidence  of  extreme  pain, 
and  no  connection  with  unpleasant  dreams,  apprehension,  or  fright. 
From  the  testimony  of  j)atients  old  enough  to  explain  symptoms, 
the  pain  is  reported  to  be  extremely  sharp  and  severe,  suddenly  in- 
terrupting sleep  and  awakening  one,  and  leaving  an  ill-defined 
sense  of  an  aching  in  the  tliigh  and  hip  as  if  the  hip  had  sustained 
a  blow. 

MiLScidar  Fixation  is  always  ]:)resent  in  some  degree,  restricting 
the  joint's  normal  arc  of  motion.  This  will  be  discussed  more  fully 
under  the  head  of  diagnosis.  Here  it  may  be  said  that  rest  to  the 
joint  and  thorough  treatment  tend  in  time  to  restore  motion  to 
the  diseased  part,  and  that  if  a  child  is  taken  under  treatment  with 
a  perfectly  rigid  joint  it  is  to  be  expected  that  under  treatment  the 
joint  will  become  more  movable  unless  the  disease  is  very  acute 
and  progressive.  Increased  stiffness  appearing  in  the  course  of 
treatment  is  a  sign  of  inefficient  treatment  or  of  extension  of  the 
disease.  The  amount  of  motion  in  the  joint  gained  at  the  close  of 
treatment  in  most  cases  diminishes  somewhat  in  after  years  with- 
out any  evidence  of  relapse;  but  in  some  cases  of  adults  who  have 
entirely  recovered  from  hip  disease  in  youth,  nearly  normal  motion 
at'the  hip  joint  may  be  found.  This  muscular  rigidity  is  the  most 
important  feature  of  the  disease,  for  not  only  is  it  the  chief  reliance 
in  the  matter  of  diagnosis,  but  it  is  the  cause  of  the  malpositions  of 
the  limb,  of  the  wearing  away  of  the  acetabulum  and  of  the  head 
of  the  bone,  and  it  lies  at  the  root  of  much  of  the  pain.  It  fur- 
nishes the  most  accurate  .index  of  the  progress  of  the  case,  and  im- 
proves or  becomes  worse  as  the  case  becomes  better  or  worse. 
The  importance  of  recognition  and  accurate  study  of  this  symptom 
cannot  be  over-estimated.  At  this  time  percussion  of  the  patella 
tendon  shows  an  increased  knee-jerk  on  the  affected  side. 

A  symptom  of  acute  hip  disease  which  has  not  received  due  at- 
tention is  a  muscular  irritability  of  the  lower  erector  spin^e  muscles 
as  well  as  of  the  muscles  directly  controlling  the  hip  joint.  If  a 
child  with  severe  hip  disease  be  laid  on  his  face  and  lifted  by  the 
legs  with  a  view  to  determining  the  flexibility  of  the  lumbar  spine, 
one  can  often  notice  the  lumbar  muscles  stand  out  like  cords,  and 
hold  the  lumbar  spine  quite  rigid.  This  often  gives  rise  to  the 
suspicion  of  the  coexistence  of  Pott's  disease.  This  symptom  is 
present  only  in  the  severe  forms  of  hip  disease. 

AtropJiy. — A  marked  atrophy  of  the  muscles  of  the  thigh  and  of 
the  glutsei  is  characteristic.  It  is  supposed  to  be  reflex  to  the  dis- 
ease of  the  joint,'  and  if  the  muscles  of  the  thigh  are  tested  for 
'  Emile  Valtat :    "  L'Atrophie  INIusc.  dans  les  Mai.  Articulaires."'     Paris. 


266  ORTHOPEDIC  SURGERY. 

contractility  to  the  irritation  of  the  faradic  current,  it  will  be  found 
that  the  contractility  is  markedly  diminished. 

Atrophy  of  the  muscles  controlling  an  inflamed  joint  begins 
early  and  may  be  very  marked,  even  in  a  simple  acute  synovitis. 
In  five  cases,  seen  by  Valtat  from  the  eighth  to  the  eleventh  day 
of  the  synovitis,  muscular  atrophy  was  present  in  all  to  the  extent 
of  at  least  two  or  three  centimetres.  The  character  of  the  joint 
disease  seems  to  matter  but  little  in  the  production  of  this  phe- 
nomenon. Traumatic  or  simple,  acute  or  chronic,  serous  or  puru- 
lent synovitis,  all  show  muscular  atrophy,  and  the  more  acute  the 
disease,  the  faster  the  wasting  goes  on.  That  this  is  something 
more  than  the  mere  atrophy  of  disuse  is  shown  by  the  fact  that  it 
begins  so  sharply  and  so  early,  that  it  is  greater  in  the  diseased 
limb  than  in  the  well  one,  even  when  the  patient  has  been  in  bed 
from  the  first,  and  that  the  muscles,  although  atrophied,  are  not 
soft  and  flabby,  but  tense.  Sir  James  Paget  says  :  "  I  wish  I  could 
explain  it  better  than  by  calling  it  reflex  atrophy,"  and  Brown- 
Sequard's  experiments  lead  him  to  think  that  the  trouble  is  an 
irritation  of  the  nerves,  and  independent  of  the  trophic  centres. 
Valtat  injected  the  joints  of  guinea-pigs  and  dogs  with  irritant 
solutions,  mustard  oil  and  ammonia,  and  found  that  muscular  atro- 
phy came  on  quickly.  In  one  case,  in  eight  days  there  had  been  a 
loss  of  thirty-two  per  cent  by  weight,  in  the  anterior  thigh-muscles, 
and  twenty-four  percent  in  the  anterior  calf-muscles;  in  another 
case  it  reached  forty-four  per  cent,  and  in  all  cases  the  extensors 
wasted  more  rapidly  than  the  flexors.  He  attributes  much  influ- 
ence in  the  matter  to  the  amount  of  pain  present,  a  point  already 
clinically  noted  by  Paget.  Valtat  also  calls  attention,  in  this  con- 
nection, to  the  paralysis  of  the  muscles  of  the  affected  limb  often 
accompanying  acute  joint  disease.  In  a  case  of  knee-joint  synovitis, 
which  he  mentions,  there  was  complete  paralysis  of  the  flexors  of 
the  leg  at  the  end  of  twenty-four  hours.  Such  a  paralysis,  to  a 
greater  or  less  degree,  seems  to  precede  the  wasting  of  the  muscles. 

This  atrophy  will  sometimes  be  absent  for  weeks  and  months, 
although  generally  it  can  be  easily  appreciated  at  an  early  stage  of 
the  disease  by  grasping  the  muscles  in  the  hand  or  by  measurement 
with  a  tape.  The  difference  in  the  circumference  of  the  two  thighs 
will  be,  perhaps,  one-quarter  of  an  inch  to  an  inch,  and  the  differ- 
ence in  the  size  of  the  calves  is  generally  about  half  of  the  thigh 
difference.  In  children  who  can  use  the  leg  fairly  well,  there 
is  rarely  any  calf  atrophy  at  the  first  examination.  The  obliter- 
ation of  the^fold  of  the  buttock  on  the  affected  side  is  a  result 
partly  of  muscular  atrophy  and  partly  of  the  periarticular  swelling 
which  accompanies  the  disease.     It  is  a  common  but  not  a  constant 


////'     D/S/'lylS/C. 


267 


symptom  at  the  early  staj^^cs  of  the  (hseasc.  It  is  also  partly  due  to 
the  flexed  attitude  of  the  limt),  which  naturally  diminislies  the 
prominence  of  the  buttock  on  that  side. 

Malpositions  of  the  Limb. — The  fixation  of  the  diseased  limb  in 
a  distorted  position  is  one  of  the  common- 
est incidents  of  the  affection.  This  is  due 
to  the  tonic  muscular  contraction  so  often 
alluded  to.  These  malpositions  arc  in  a 
position  of  flexion,  of  adduction,  of  abduc- 
tion, and  of  eversion.  Flexion  of  the  thigh 
was  originally  supposed  to  be  due  to  an  effu- 
sion in  the  capsule  of  the  hip-joint,  but  it 
is  seen  along  with  adduction  and  abduction 
in  cases  where  no  effusion  has  taken,  place. 
It  is  chiefly  due  to  the  muscular  contraction, 
which  is  constant  in  chronic  disease  of  the 
joint,  and  partly  to  an  unconscious  effort  on 
the  part  of  the  patient  to  assume  a  position 
most  comfortable  for  the  joint  and  most 
protected  from  jar.'  In  double  hip  disease 
flexion  produces  a  terrible  deformity.  As 
the  disease  progresses,  adduction  or  abduc- 
tion of  the  limb  takes  place,  and  the  attitude 
of  flexion  and  adduction  is  characteristic  of 
the  last  stage  of  the  affection.  Abduction 
and  adduction  of  the  diseased  limb  are 
present  in  most  cases  sooner  or  later.  Nei- fig.  263— Flexion  and  Abduction, 
theris  characteristic  of  the   early  stage,  al-  (From  a  Photograph.) 

though  abduction  is  often  stated  to  be,  but  many  cases  begin  and 
continue  as  adduction.  These  deformities  generally  disappear 
under  treatment  by  rest  or  traction ;  but  again,  they  appear  in  cases 


Fig.  264. — Severe  Abduction  and  Eversion  occurring  in  a  very  acute  case. 

under  treatment,  and  they  go  hand  in  hand  with  a  sensitive  con- 
dition of  the  joint  which  may  be  the  precursor  of  abscess. 

»  Lannelongue  :   "  Coxotuberculose,"  Paris,  1885;  Hilton:  "  Rest  and  Pain,"  London. 


268 


OR  THOPEDIC  S  URGER  Y. 


Bonnet,  of  Lyons,  investigated  this  question  of  malposition  in 
inflammation,  making  some  experiments  which  have  become  classi- 
cal, and  until  lately  his  theory  met  with  universal  acceptance. 
Joints  in  the  cadaver  were  injected  with  fluid  by  means  of  an  ordi- 
nary hand  syringe,  and  Bonnet  found  that  the  limbs  assumed  the 
same  positions  as  when  inflamed  during  life.  He  concluded  that 
the  limb  simply  assumed  the  position  in  which  the  joint  would 
hold  the  most  fluid.  But  certain  objections  were  urged  against 
this  theory.  Bonnet's  injections  had  been  made  with  so  much 
pressure    that    the    condition    of  affairs    in    the    joint  was    not    to 


Fig.  265. — Adduction. 

be  compared  with  that  in  acute  synovitis.  There  are  two  very 
forcible  clinical  objections — certain  cases  of  knee-joint  disease,  for 
example,  with  an  extreme  amount  of  effusion,  present  little  or  no 
flexion,  and  in  the  whole  class  of  chronic  tuberculous  joint  diseases, 
where  the  malpositions  are  most  marked  and  most  constant,  effu- 
sion is  most  often  absent  or  very  slight  in  amount.  All  this,  of 
course,  points  to  some  second  factor  in  originating  and  maintain- 
ing these  positions.  The  explanation  of  Hilton  represents  the 
other  point  of  view;  he  says  "  that  the  irritated  or  inflamed  condi- 
tion of  the  interior  of  the  joint  (say  the  knee-joint),  involving  the 
whole  of  the  articular  nerves,  excites  a  corresponding  condition  of 


////'    niSI'lASE. 


2G) 


irritation  in  the  snmc  trunks  wliicli  supply  both  sets  of  muscles, 
extensors  and  flexors;  but  that  tlie  flexors,  by  virtue  of  their 
superior  strength,  compel  the  limb  to  obey  them,  and  so  force  the 
joint  into  its  flexed  condition."  This  i)hase  of  the  question  is  elab- 
orated a  Httle  more  fully  by  Liicke,  who  says  that  the  extensors 
are  lighter  in  color,  and  are  not  so  well  supplied  with  blood,  and 
that  impairment  of  motor  functions,  after  fatigue  from  electrical 
stimulation,  is  more  marked  in  the  exten- 
sors than  in  the  flexors.  In  summing  up, 
Liicke  offers  practically  tlie  same  expla- 
nation that  Hilton  does,  saying  that  the 
patient  finds  it  most  comfortable  to  hold 
the  limb  in  this  position,  all  the  muscles 
being  tense  and  set,  but  at  present,  the 
question  of  position  of  the  limbs  in  in- 
flamed joints  is  not  thoroughly  under- 
stood. 


Fig.  266.— Adduction  of  the  Left  Leg  in  Acute  Hip 
Disease. 


Fig.  267. — Stanam^  PoMtion  assumed  in  Right 
Hip  Disease  where  Flexion  and  Abduction  are 
Present  to  a  Moderate  Degree. 


The  occurrence  of  abduction  or  adduction  in  the  course  of  the 
disease  is  a  very  common  and  very  troublesome  matter.  As  a 
rule,  the  symptom  indicates  that  the  disease  is  not  arrested,  or  is 
progressing,  and  the  occurrence  or  increase  of  malposition  is  almost 
always  accompanied  by  an  increase  of  muscular  fixation,  and  often, 
as  will  be  seen,  this  precedes  abscess  formation.  If  the  malposition 
is  allowed  to  become  permanent,  the  final  result  can  never  be  so 


2/0 


ORTHOPEDIC  SURGERY. 


good  as  where  ankylosis  takes  place  in  a  more  normal  position. 
The  limp  in  an  ankylosed  limb  depends  more  upon  the  amount  of 
adduction  than  on  anything  except  perhaps  the  bone  shortening. 
It  is,  therefore,  of  much  importance  to  be  able  to  estimate  with 
reasonable  accuracy  the  amount  of  malposition  present. 

When  adduction  is  present  in  both  legs,  as  in  double  hip  disease, 
an'd  ankylosis  of  both  hips  has  occurred,  cross-legged  progression. 


Fig.  268. — Crossed  Leg  Progression,  the  Result 
of  Double  Hip  Disease. 


Fig.  269. — Position  assumed  in  Standing  and  Walking 
where  Flexion  of  the  Right  Hip  is  Present. 


as  shown  in  the  figure,  is  made  necessary  on  account  of  the  inability 
to  separate  the  legs.  It  is,  of  course,  an  extremely  awkward  way 
of  walking,  but  persons  afflicted  with  the  deformity  are,  neverthe- 
less, not  entirely  incapacitated  from  going  about.  The  position  in 
standing  and  lying  is  modified  by  the  occurrence  of  these  malposi- 
tions ;  abduction  or  adduction  causes  tilting  of  the  pelvis  and  char- 
acteristic postures  which  are  seen  in  the  figures.  In  the  same  way 
flexion  causes  a  marked  lordosis  of  the  lumbar  spine  in  standing 
with  the  legs  together;  by  standing  with  the  diseased  leg  some- 


////'      J)lSh:ylSlL. 


271 


what  flexed  the  lordosis  can  be  overcome.  The  fij^ure  sh(;ws  the 
effect  of  flexion  in  producing  lordosis  <~A  the  lumbar  spine  when  the 
flexed  leg  is  made  straight.  This  occurs  when  the  patient  lies  on  a 
table  and  the  flexed  leg  is  brought  down  or  when  he  stands  erect, 
with  knees  together.  The  recognition  of  inaljjosition  is  not  of  great 
diagnostic  importance,  because  the  muscular  s]nism  which  causes  it 


^ 


Fig.  270. — Moderate  Flexion  in  Right  Leg  but  Fig.  271. — Position  assumed   m  Standing  in  Right 

Obliteration    of    the  Lordosis   in    the    Lumbar  Hip  Disease  where  Fle.xion  is  more  Severe,  showing  the 

Spine  by  not  attempting  to  place  the  Right  Foot  IMarked  Lordosis  of  the  Lumbar   Spine  owing  to  the 

on  the  Ground.  placing  of  the  Right  Foot  on  the  Ground. 

is  of  so  much  more  significance,  but  the  presence  of  malposition  has 
a  most  marked  effect  in  modifying  the  treatment  of  the  affection. 

Pcri-articnlar  Syviptovis. — A  tenseness  in  the  superficial  tissues 
over  a  diseased  hip  which  the  other  side  does  not  possess  is  often 
found  at  a  comparatively  early  stage  of  the  affection.  Behind 
the  trochanter  the  deep  tissues  are  resistant  and  the  fossa  existing 
there   is   filled   out,  and  the  great   trochanter   may  be   apparently 


2/2 


OR  THOPEDIC  S  URGER  Y. 


thickened,  but  no  very  great  importance  can  be  attached  to  this, 
although  Wright  considers  it  pathognomonic  of  suppuration  in  the 
joint.  The  inguinal  glands  of  the  affected  side,  in  fact  of  both 
sides,  are  often  enlarged  and  they  may  be  so  much  distended  that 
they  obstruct-the  venous  return  and  the  skin  is  marbled  with  super- 
ficial veins.  They  are  at  times  the  seat  of  superficial  abscesses. 
In  very  severe  cases  the  upper  part  of  the  thigh  and  the  tissues  in 
the  vicinity  of  the  hip  may  become  swoljen  generally — an  oedema 
of  the  periarticular  tissues  takes  place,  similar  to  that  seen  in  the 
knee  in  the  so-called  "tumor  albus;  "  this  may  disappear  or  be- 
come localized  in  the  fornnation  of  an  abscess.  A  thickening  over 
the  tensor  vaginse  femoris  is  often  to  be  felt. 

Abscess. — In  quite  a  large  proportion  of  cases  suppuration  takes 
place,  and  the  severer  forms  are  accompanied  by  much  pain.  The 
site  and  course  of  the  abscesses  vary  according  to  the  seat  and  size 
of  the  original  focus  of  the  ostitis,  whether  in  the  femur  or  acetabu- 


FiG.  272. — Lordosis  Resulting  from  bringing  the  tlexed  Leg  in  Hip  Disease  Parallel  to  the  Other. 


lum.  Abscesses  may  be  entirely  peri-articular,  if  the  initial  lesion 
of  the  epiphysis  extend  in  a  course  outside  of  the  joint ;  or  they 
may  come  from  suppuration  within  the  joint ;  or  having  been 
peri-articular,  they  may  later  involve  the  joint. 

The  invasion  of  the  abscess  is  frequently  without  constitutional 
disturbance,  as  is  not  infrequent  in  cold  abscesses  in  general. 
There  may,  however,  be  a  slight  fever.  As  the  abscesses  enlarge 
they  are  usually  accompanied  by  the  pallor  incidental  to  suppura- 
tion— the  suppurative  leucocythsemia  characterized  by  an  increase 
in  the  number  of  white  corpuscles.  This  condition  may  not  inter- 
fere with  a  fair  appetite  and  more  or  less  satisfactory  general 
health,  but  as  a  rule  the  appetite  is  capricious.  Abscesses  may  be 
absorbed  spontaneously  or  discharge  themselves.  They  may  evac- 
uate themselves  nearly,  the  residual  fluid  following  along  the 
course  of  the  sheaths  of  the  muscles  and  the  fasciae,  reappearing 
later  as  secondary  abscesses,  the  same  abscess  causing  five  or  six 
fistulous  openings.     These   openings  discharge  pus  and  serum  for 


////'   J)/SJCASE. 


273 


months  and  years  in  most  cases.  With  tlic;  bursting  of  an  ab- 
scess, and  the  discharge  of  any  considerable  quantity  of  pus  the 
patient's  condition  may  rapidly  deteriorate  or  the  condition  may 
be  only  temporary  and  be  followed  by  marked  improvement. 

When  the  pus  has  left  the  joint  it  generally  burrows  between  the 
thigh  muscles  to  reach  the  skiii,  where  it  appears  as  a  tense  swelling 
of  varying  size.  Pluctuation  is  usually  marked.  As  the  abscess 
invades  the  skin  the  latter  becomes  thin  and  red,  and  ulcerates  in 
one  or  two  places,  evacuating  the  abscess.  The  contents  of  the 
abscess  may,  however,  in  a  few  instances  be  \ 

absorbed  even  at  a  stage  v/hen  fluctuation 
is  marked,  and  the  swelling  may  disappear, 
leaving  a  depression  beneath  the  skin. 

The  pus  most  commonly  reaches  the  skin 
at  the  anterior  border  of  the  tensor  vaginse 
femoris  muscle,  it  may,  however,  gravitate 
backward  and  open  back  of  the  great  tro- 
chanter or  at  the  lower  border  of  the  glu- 
teus maximus;  it  may  come  around  to  the  ' 
inner  side  of  the  thigh  and  perhaps  open  in 
front  of  the  adductor  tendons  or  even  dis- 
charge into  the  rectum:  finally  it  may  as- 
cend the  sheath  of  the  psoas  muscle  and 
point  above  Poupart's  ligament,  or  it  may 
descend  in  the  thigh  muscles  and  point  in 
the  popliteal  space.  It  has  been  said  that 
the  seat  of  the  primary  disease  can  be  in- 
ferred by  the  situation  of  the  abscess;  but 
enough  facts  have  not  yet  been  obtained  to  z^ 
justify  such  generalization.                                     "'^ 

Probably  abscess  is  very  often  the  result  of  ^/n 
inefficient  treatment.    As  a  rule,  it  does  not  ^^  at  ./-  t     ►■ 

'  r  IG.  273. — Most  Common  J^ocation 

come  on  in  cases  of  hip  disease,  which  are  of  Hip  Abscess. 

doing  well,  when  muscular  fixation  is  slight  and  motions  are  pain- 
less ;  but  it  comes  in  cases  where  malposition  of  the  limb  is  present 
with,  perhaps,  complete  muscular  fixation  and  often  a  painful  con- 
dition of  the  joint.  The  waiters  are  inclined  to  believe  from  their 
experience  that  malpositions  very  generally  precede  abscess  forma- 
tion. This  opinion  has  been  sustained  by  an  investigation  of  the 
records  at  the  Children's  Hospital  for  the  last  five  years.  Formerly 
cases  of  hip  disease  were  onl}'  admitted  to  the  hospital  wards 
when  abscess  appeared,  or  when  such  serious  malposition  of  the 
limb  occurred  as  to  render  further  ambulatory  treatment  impossi- 
ble.    Of  late  the  manner  of  admission  of  these  patients  has  been 


\ 


274 


ORTHOPEDIC  SURGERY. 


SO  modified  that  now  the  occurrence  of  adduction,  abduction,  or 
flexion  under  treatment  has  been  considered  as  an  indication  for 
admission  to  the  hospital,  and  an  attempt  at  gradual  reduction  of 
the  deformity  by  bed  extension.  While  this  modification  of  the 
plan  of  treatment  has  been  coming  about,  the  number  of  hip  ab- 
scesses has  been  steadily  diminishing,  although  the  number  of  cases 
of  hip  disease  treated  has  steadily  increased  until,  in  1888,  there 
were  only  eleven  hip  abscesses  operated  on  in  300  to  400  cases  of 
hip  disease  treated  by  ambulatory  methods  in  the  outdoor  depart- 


FiG.  274. — Hip  Abscess,  with  Deep 
Fluctuations  at  the  Anterior  and 
Upper  Part  of  the  Thigh. 


Fig.  275. — Adduction  and 
Bone  Shortening  with  Atro- 
phy of  the  Right  Leg. 


Fig.  276. — Shorte 
genital  Dislocation 


ning  in  Con- 
of  the  Hip. 


ment  of  the  hospital.     And  all  abscesses  which  occurred  were  ope- 
rated upon  with  but  two  exceptions.' 

Shortening. — -The  effect  of  persistent  muscular  spasm  of  muscles 
about  the  hip-joint  characteristic  of  hip  disease,  is  to  crowd  the 
femur  against  the  acetabulum.  The  amount  of  the  force  may  be 
estimated  as  relatively  great,  if  we  bear  in  mind  the  strength  of  the 
affected  muscles.  The  result  of  this  force  is  to  produce  the 
pseudo-luxation  characteristic  of  hip  disease,  viz.,  the  enlargement 

'  Boston  Medical  and  Surg.  Journ.,  Nov.  2ist,  1S89,  p.   503. 


////'    DISEASE.  275 

• 

of  the  acetabulum  and  the  absorption  of  the  head  of  the  femur, 
with  resulting  shortening  of  the  limb;  and  in  certain  cases  the 
actual  escape  of  the  head  of  the  femur  from  the  socket. 

In  addition  to  the  shortening  produced  by  absolute  destruction 
of  bone  in  the  femur  or  the  acetabulum,  there  is  a  decitied  trophic 
disturbance  of  the  limb  which  results,  as  has  been  seen,  in  wasting, 
and  which  also  has  an  effect  in  retarding  the  bony  growth  and 
probably  causes  at  the  same  time  a  certain  amount  of  bone  atro- 
phy; retarded  growth  of  the  affected  limb  becomes  evident  in  the 
early  months  of  the  disease,  and  is  a  permanent  condition  which 
is  not  outgrown  as  years  go  on,  for  the  affected  limb  always  lags 
behind  the  other  in  its  growth. 

In  studying  the  general  effect  of  shortening,  it  is  found  to  exist 
principally  in  the  femur,  though  the  tibia  shares  in  it  to  a  less 
extent  also.  The  shortening  of  the  thigh  is  ordinarily  about  two- 
thirds  of  the  whole,  but  sometimes  it  is  less,  and  it  may  be  wholly 
in  the  femur.  When  there  is  much  shortening  of  the  leg,  the  foot 
of  the  affected  side  is  also  smaller  than  the  other.  The  difference 
in  the  length  of  the  legs  almost  always  increases  slightly  after  the 
disease  is  cured,  as  was  shown  in  the  series  of  cured  cases  of  hip 
disease  analyzed  by  Shaffer  and  Lovett.'  In  these  cases  at  the 
time  of  discharge  from  hospital  treatment  and  supervision,  care- 
ful measurements  were  made  and  recorded  in  twenty  cases.  At 
that  time  the  shortening  varied  from  half  an  inch  to  an  inch  and  a 
half,  and  in  only  four  cases  was  it  as  much  as  two  inches.  Several 
years  afterward  these  cases  showed,  almost  wathout  exception,  an 
increase  in  the  amount  of  shortening.  In  five  cases  it  was  an  inch 
or  less,  and  the  rest  showed  from  one  and  a  half  to  two  and  a  half 
inches  difference.  The  legs  had  grown  meantime  five,  ten,  or  e\-en 
fifteen  inches,  so  that  the  shortening  was  not  in  any  case  excessive. 
It  also  seems  that  the  shortening  does  not  increase  indefinitely,  for, 
in  the  cases  where  eight  or  ten  years  had  elapsed  between  the  two 
measurements,  there  was  no  greater  shortening  than  when  three, 
four,  or  six  yeaps  had  elapsed.  The  amount  of  shortening,  as  after 
excision,  may  be  supposed  to  depend,  in  a  measure,  upon  the  de- 
struction by  the  disease  of  the  epiphysis,  but  this  can  onh-  partially 
explain  the  facts,  as  limitation  in  the  growth  of  the  tibia  and  foot 
also  occurs  in  some  instances. 

General  Condition. — Children  with  hip  disease  are  often  robust 
at  the  beginning  of  the  afTection  and  sometimes  the  general  condi- 
tion continues  good  to  the  end,  but  these  cases  are  exceptional. 
More  often,  after  some  months  the  child  becomes  pale  and  the 
appetite  fails  at  times;  often  it  does  not  go  any  further  than  this; 
'  N.  Y.  Med.  Journal,  May  21st,  1SS7. 


276  ORTHOPEDIC  SURGERY. 

but  at  other  times  decided  constitutional  disturbance  results.  Any 
account  of  the  symptoms  of  hip  disease  would  be  incomplete  with- 
out speaking  of  the  remissions  in  the  course  of  the  affection  which 
have  attracted  but  slight  attention.  In  the  early  stage  this  is  es- 
pecially noticeable,  and  a  case  may  to  outside  appearances  entirely 
recover  from  the  symptoms  of  pain,  lameness,  and  discomfort  for 
some  days  or  weeks.  Then  the  symptoms  return  with  increased 
vigor,  perhaps  to  disappear  again  in  a  short  time.  The  muscular 
stiffness  does  not  wholly  disappear  at  these  times,  although  it  may 
improve  along  with  the  other  manifestations  of  the  disease.  The 
later  course  of  the  disease  is  marked  by  much  greater  uniformity, 
but  even  then  slight  temporary  improvement  may  be  quite  marked. 
Temperature.— Vc  seems  probable  that  the  temperature  of  chil-' 
dren  with  marked  hip  disease  is  somewhat  higher  than  has  been 
supposed.  The  following  table  shows  the  result  of  taking  the  tem- 
perature in  a  consecutive  series  of  cases  of  hip  disease  of  all  sorts 
and  stages,  as  they  attended  the  out-patient  department.  They 
were  taken  late  in  the  afternoon  with  a  standardized  thermom.eter, 
and  no  cases  wefe  omitted.  The  cases,  it  may  be  emphasized  again, 
were  not  selected  for  their  severity,  but  were  both  light  and  severe 
and  represented  a  very  fair  average. 

Table   Showing  the  Temperature   of   Children  with  Hip 

Disease. 


99.8 

100.2 

99.1 
100.5* 

100.3 
100.9* 

100.2* 

IOI.2 

99-3 
102.4* 

lOI.I* 

100.5 

I0I.8 
99.2 
102. 

99.9 

997 
98.7 

997 
100.7''- 
101.9 

As  a  check  to  this  observation  the  following  temperatures  were 
taken  of  healthy  children  at  the  same  clinic  under  the  same  condi; 
tions. 

99-3  98-5  97-3 

98.  99.3  99.3 

99.3  98.  99.1 

99.1  98.1  97.3 

98.3  98.5  97.3 

Double  Hip  Disease.— ^\dXon  states  that  the  disease  seldom  begins 
in  both  hip  joints  at  the  same  time  and  that  the  second  joint  may 
become  inflamed  while  the  patient   is  under  treatment  in   bed  for 

*  Cases  marked  with  an  asterisk  had  discharging  sinuses. 


////'   niSI'lASE. 


277 


the  first  joint,  showin^^  that  traumatism  inay  be  cxchidcd  as  a  cause 
of  the  disease. 

This  corresponds  witli  tlie  experience  of  tlie  writers,  who  have 
observed  several  cases  of  double  hip  disease  where  the  second  joint 
was  affected  during  the  careful  treatinent  by 
fixation  of  the  first.  The  course  of  double  hip 
disease  would  appear  to  vary  somewhat  from 
that  of  single  hip  disease.  The  amount  of 
pain  suffered  in  the  joint  last  affected  is  usu- 
ally less  than  that  of  the  first  joint,  probably 
because  there  is  less  jar  or  motion  when  two 
hip-joints  are  affected  than  when  one  is 

Hip   disease,  like    all   dis- 


eases,  is    a    self-limited  one. 
A    natural  cure  takes  place 
in    a    majority  of  cases,  but 
the  cycle  of  invasion,  efflor- 
escence,  convalescence,   and 
cure,    always     consumes    a    long 
period  of  timiC.     The  natural  cure 
in  the  lightest  cases  leaves  a  slight 
limitation    of  motion    in  the  hip. 
This  is  accompanied  by  a    slight 
limp.      More  frequently  there  is 
practical    stiffness    at    the    joint, 
with  fibrous  or  eventual  bony  an- 
kylosis at  the  hip-joint,  and  prob 

,,Q        .  J         11        .•  Til  ^\G.  277.— Permanent  Position  necessitated  bv 

ably   HeXlOn   and    adduction   Ot     the       the  Flexion  Deformity  resulting  from  Double  Hip 

limb    with    practical    shortening.     Disease. 

Subluxation  of  the  femur  with  shortening  of  the  limb  is  a  common 
result  of  the  natural  cure,  and  an  arrest  of  growth  with  actual  short- 
ening of  the  bone.  A  most  distressing  deformity  may  follow  the 
natural  cure  of  double  hip  disease.  This  may  leave  severe  flexion  of 
both  femora,  or  flexion  and  adduction  so  that  the  limbs  are  crossed. 


Diagnosis. 


The  diagnosis  of  hip  disease  ma}^  be  easy  or  difificult ;  in  the 
earliest  stages,  errors  in  it  are  sometimes  made,  and  care  is  neces- 
sary for  a  positive  diagnosis  in  any  stage.  The  most  common 
error  is  the  belief  that  the  presence  of  pain  or  tenderness  is  neces- 
sarily present  in  hip  disease,  and  its  absence  excludes  the  possibility 
of  hip  disease.  Pain  or  tenderness  are  not,  however,  early  symp- 
toms in  a  majority  of  cases.     Another  error  often  made  is  to  look 


278  ORTHOPEDIC  SURGERY. 

for  "grating"  in  the  joint  as  a  sign  of  the  disease.  That  sign  is 
only  to  be  obtained  by  the  use  of  an  anaesthetic  by  which  means 
the  muscles  guarding  the  joint  are  relaxed.  In  any  event  bony 
grating  can  be  obtained  only  in  advanced  cases  when  two  bony 
and  eroded  surfaces  lie  in  contact,  and  rub  upon  each  other  when 
the  joint  is  manipulated. 

The  diagnostic  symptoms  in  hip  disease  which  should  be  borne 
in  mind  in  making  a  diagnosis  of  hip  disease  are  as  follows: 

1.  Stiffness  of  the  joint;  tonic  muscular  spasm. 

2.  Lameness ;  limp  in  gait. 

3.  Attitude  of  the  limb  in  standing,  or  walking,  or  in  lying,  ad- 
duction and  abduction  of  the  limb. 

4.  Atrophy. 

5.  Pain. 

6.  Swelling, 

These  symptoms  vary  in  prominence  at  different  stages  and 
activity  of  the  disease. 

In  brief  it  may  be  said  that  the  early  diagnosis  must  be  made 
chiefly  by  the  symptom  of  muscular  rigidity.  The  absence  of 
pain  or  sensitiveness  counts  for  nothing  and  atrophy  is  not  charac- 
teristic. The  limp  is  peculiar,  but  a  similar  one  is  present  in  other 
conditions. 

The  diagnostic  importance  of  the  other  symptoms  will  be  con- 
sidered in  detail. 

Stiffness  ox  tonic  muscular  spasm,  the  chief  diagnostic  sign  in  hip 
disease,  upon  which  the  chief  reliance  must  always  be  placed,  is  the 
presence  of  stffness  of  the  joint  or  limitation  of  its  proper  arc  of 
motio7i  when  the  limb  is  passively  manipulated.  Except  in  the 
very  earliest  stages  there  can  be  no  hip  disease  without  a  percep- 
tible limitation  of  motion,  and  even  then  Valette '  'claims  there  can 
be  no  hip  disease  if  the  motions  at  the  hip-joint  are  perfect.  In 
one  case  examined  in  the  very  earliest  stage,  which  afterward  proved 
to  be  hip  disease,  the  motion  at  the  hip-joint  on  one  examination 
appeared  to  be  perfect ;  but  on  a  second  examination  the  next 
day,  after  a  little  exercise,  it  gave  evidence  of  slight  limitation  of 
motion. 

This  limitation  of  motion  is  not  the  result  of  adhesions  or  begin- 
ning ankylosis  in  early  hip  disease,  but  it  is  the  result  of  a  tonic 
contraction  of  the  muscles  controlling  the  joint,  and  disappears 
under  anaesthesia  in  the  early  stages  of  the  disease. 

In  the  detection  of  this  most  important  diagnostic  sign  it  should 
be  borne  in  mind  that  some  care  is  required  to  discover  slight  lim- 
itation  of  motion  in  very  young  children,  who  are  apt  to  resist 
'  "  Nouveau  Diet,  de  Med.  and  Chir." 


////'   DISEASE.  2/9 

thorough  examination.  Tlic  resistance  to  motion  due  to  fright  is, 
however,  always  resistance  to  all  motions  of  the  limb;  if  by  slight 
force  this  is  overcome,  resistance  to  rotation  of  a  flexed  thigh,  or 
to  extreme  flexion,  will  not  be  encountered.  A  comparison  of  the 
resistance  of  one  leg  with  that  of  the  other  will  reveal  abnormal 
resistance.  Limitation  to  motion  at  the  hip-joint,  in  the  early 
stages,  is  at  the  extremity  of  the  arc  of  normal  movement,  i.e., 
flexion,  extension,  abduction,  or  adduction.  The  normal  amount 
of  abduction  is,  however,  slight,  and  resistance  to  motion  in  this 
direction,  therefore,  is  an  early  test  of  importance.  Extreme  ab- 
duction, or  adduction,  and  rotation  of  the  thigh  flexed  at  right 
angles  to  the  body,  is  also  a  delicate  test. 

In  young  and  frightened  children,  the  tests  for  limitation  of 
motion  at  the  hip-joint  are  best  made  with  the  children  lying  on 
the  mother's  lap,  or  leaning  on  the  mother's  shoulder.  In  exam- 
ining the  patient  for  muscular  stiffness,  the  clothes  should  be 
removed  and  the  patient  should  lie  upon  a  hard  surface  (except 
in  the  case  of  an  infant  in  arms,  as  above  mentioned).  At- 
tempts to  move  the  limb  should  be  made  gradually,  gently,  and 
persistently — rough  force  only  exciting  resistance  and  making  a 
delicate  examination  impossible.  The  most  convenient  order  of 
motion  in  examination  is  first  flexion,  then  abduction  and  abduct- 
ing rotation  with  the  thigh  flexed,  then  extension.  The  suspected 
limb  should  be  held  at  the  ankle  or  knee  with  one  hand,  while  the 
other  hand  will  grasp  the  pelvis  to  ascertain  when  motion  in  the 
joint  ceases  and  movement  of  the  pelvis  begins.  Examination 
under  anaesthesia  shows  nothing,  at  the  early  stage  of  hip  disease, 
as  muscular  spasm,  a  most  important  diagnostic  sign,  has  been 
overcome  and  is  absent.  A  limitation  to  flexion  is  determ.ined  by 
flexion  of  the  normal  limb  on  the  abdomen  to  its  utmost  limit,  and 
afterward  a  repetition  of  the  motion  of  the  suspected  limb.  If  the 
limb  is  then  extended  so  that  the  popliteal  space  be  placed  upon 
the  hard  surface  on  which  the  patient  lies,  normally  there  will  be 
no  alteration  of  the  position  of  the  back;  if,  however,  there  is  a 
contraction  of  the  psoas  and  iliacus  muscles,  i.e.,  a  limitation  in  the 
normal  extension  of  the  limb,  the  back  will  be  arched  up  as  the 
popliteal  space  is  pressed  down. 

This  limitation  to  extension  can  also  be  determined  by  examin- 
ing the  patient  lying  upon  the  belly.  If  one  hand  be  placed  on  the 
sacrum  and  the  thighs  be  alternately  raised  from  the  surface  on 
which  the  patient  lies,'  a  difference  in  the  amount  of  motion  at  the 
hip  without  moving  the  sacrum  can  easily  be  determined  l^Fig.  2'jZ\. 
The  lim.it  to  the  amount  of  abduction  or  adduction  is  determined 
by  placing  one  hand  on  the  anterior  superior  spine  of  the  ilium  on 


28o 


ORTHOPEDIC  SURGERY. 


the  sound  side,  and  with  the  other  hand  gently  abducting  or  ad- 
ducting  the  suspected  limb,  where  limitation  is  present  the  pelvis 
of  course  moves  with  the  diseased  limb. 

Careful-  inspection  in  the  early  stages  of  hip  disease  will  some- 
times show  fibrillary  contraction  of  the  muscles  of  the  thigh  on 
sudden  or  unexpected  movement  of  the  limb. 

In  the  later  stages  of  hip  disease  practical  ankylosis  of  the  joint 
takes  place,  there  being  no  motion  at  the  hip-joint.  This  is  due  to 
muscular  spasm  and  disappears  under  complete  anaesthesia,  unless 
a  permanent  degeneration  of  the  muscle  has  taken  place,  or  a 
fibrous  ankylosis  of  the  hip-joint  has  begun  to  be  developed. 

A  limitation  to  rotation  at  the  hip  is  not  so  readily  detected  in 
the  earliest  stages  of  hip  disease.  Often  the  foot  can  be  turned 
in  and  out  with  apparent  normal  freedom ;    if,  however,  the  thigh 


Fig.  278.— Method  of  Determining  the  Limitation  of  Extension  in  Hip  Disease. 


be  flexed   upon  the  abdomen,  and  an  attempt  be  made  to  rotate 
the  femur  and  at  the  same  time  abduct  it,  at  a  very  early  stage,  ' 
unusual  resistance  to  this  motion  will  be  found  on  the  affected  side 
as  compared  to  the  normal  side. 

It  is  not  possible  to  say  just  what  degree  of  fixation  spasm  on 
the  part  of  the  muscles  can  be  accepted  as  evidence  of  disease  of 
the  joint.  Any  catch  in  the  motion  of  the  joint  in  any  part  of  its 
arc  is  exceedingly  suspicious,  no  matter  how  slight  it  may  be.  And 
any  considerable  degree  of  fixation  may  be  regarded  as  almost 
pathognomonic  of  hip  disease,  especially  when  it  is  a  loss  of  abduc- 
tion, of  hyper-extension  and  of  external  rotation,  the  first  motions 
as  a  rule  to  be  restricted  in  true  hip  disease. 

Lameness. — Another  diagnostic  sign  of  value  is  a  limp  in  gait, 
which  is  an  early  symptom,  in  fact  the  earliest  symptom.  It  may 
be  said  that  no  hip  disease  can  be  present  without  giving  rise  to  it. 
At  the  earliest  stages,  however,  the  limping  may  be  intermittent 
and  not   constant,  and  again,  it   may  be  so  slight  that  it  is  prac- 


////'    DISEASE.  281 

tically  imperceptible,  so  tliat  its  absence  does  not  exclude  liij;  dis- 
ease. Its  character  has  jjeen  ah'eady  descrijjed,  and  tiie  fact  that 
it  is  worse  in  the  morning  than  at  iiigiit,  but  these  are  not  alto- 
gether distinctive  and  the  diagnosis  cannot  be  made  alone  from 
watching  the  child, wafk.  Only  lately  a  case  came  under  the  ob- 
servation of  the  writers  where  the  limp  of  hip  disease  was  perfectly 
simulated  by  a  child  who  had  a  very  slight  infantile  paralysis  of  the 
muscles  of  one  leg,  and  a  similar  walk  is  seen  in  other  conditions, 
such  as  sprains  of  the  hip. 

Attitudes  and  Shortening  of  the  Limb. — Abnormal  positions  of  the 
diseased  limb  are  caused  by  muscular  contraction  holding  the  limb 
stiffly  in  distorted  position.  Neither  adduction  nor  abduction  of 
the  limb  are  usually  recognized  by  the  patient  as  such,  but  the 
complaint  is  made  that  the  limb  seems  longer  or  shorter  than  the 
other.  The  pelvis  is  tilted,  which  gives  a  practical  lengthening  of 
the  limb,  and  in  the  same  way  the  limb  appears  shorter  to  the 
patient  if  adducted.  The  tilting  of  the  pelvis  can  be  recognized  by 
drawing  a  line  from  the  anterior  superior  spine  of  one  side  to  that 
of  the  other.  This  should  be  at  right  angles  with  a  line  from  the 
umbilicus  to  the  symphysis  pubis.  In  this  way  have  arisen  the 
terms  of  apparent  or  practical  shortening  and  lengthening  which 
have  given  rise  to  some  obscurity. 

The  accompanying  diagrams  will  explain  the  matter;  The  nor- 
mal position  of  the  pelvis  in  relation  to  the  limbs  is  shown  in  heavy 
lines  in  Fig.  i,  where  both  legs  are  at  right  angles  to  the  pelvis,  the 
normal  position  for  standing  and  walking.  If,  however,  the  right 
leg  is  fixed  by  muscular  spasm  in  an  adducted  position,  AE,  the 
relation  is  changed,  and  when  the  patient  stands  erect  the  legs 
must  be  made  parallel  to  permit  walking  or  standing  on  both  feet, 
and  this  can  only  be  done  by  tilting  the  pelvis  to  the  position 
shown  in  Fig.  2.  It  will  be  seen  by  the  tilting,  that  the  leg  AC  is 
carried  up  with  that  side  of  the  pelvis  and  to  all  appearances  the 
leg  AC  is  shorter  than  the  leg  BD,  when  the  patient  stands  or  lies 
straight.  Thus  adduction  results  in  apparent  shortening  of  the 
adducted  limb  as  compared  with  the  other  when  the  patient  lies 
straight.  In  the  same  way  in  Fig.  3,  if  the  leg  AC  is  abducted  co 
the  position  AF,  the  pelvis  must  be  tilted  in  the  opposite  direction 
to  make  the  legs  parallel,  because  the  angle  F  A  B,  is  a.  fixed 
quantity,  and  so  the  pelvis  is  tilted,  and  AC,  for  practical  purposes 
is  longer  than  BD,  and  the  amount  of  apparent  lengthening  de- 
pends upon  the  amount  of  abduction. 

A  patient  then  with  adduction  of.  one  leg  has  a  deformit}*  which 
results  in  a  lifting  of  that  leg  from  the  ground  when  he  stands  or 
walks,  for  the  tilting  of  the  pelvis  has  caused  a  practical  shortening 


282 


OR  THOPEDIC  S  URGER  V. 


of  that  leg.  In  the  same  way  abduction  causes  the  opposite  tilting- 
of  the  pelvis  and  a  practical  lengthening  of  the  diseased  leg.  So 
that  the  term  apparent  or  practical  shortening,  can  be  applied  to 
the  inequality  of  the  legs  noticed  in  walking  or  standing,  which 
results  from  the  tilting  of  the  pelvis.  Practical  shortening  can  be 
estimated  by  measuring  from  the  umbilicus  to  each  malleolus  when 
the  patient  lies  or  stands  straight. 

Real  or  bone  shortening  is  entirely  different  from  apparent  short- 
ening. It  results  from  the  retarded  growth  of  the  affected  limb  or 
from  the  destruction  of  bone  in  the  hip 
joint,  and  is  independent  of  the  amount 
of  adduction  or  abduction.  Real  short- 
ening is  measured  by  a  tape  from  the 
anterior  superior  spines  of  the  ilium  to 
the  inner  malleolus  on  each  side. 

It  is  important,  in  an  examination  for 
hip  disease,  to  determine  the  amount  of 
permanent  injury  which  the  disease  has 
already  inflicted.     The    amount    of    en- 


FiG.  280. — Diagram  showing  Practical  Shortening- 
of  the  Right  Leg  from  Adduction. 


largement  of  the  acetabulum  and  absorption  of  the  head  of  the 
femur  which  has  taken  place,  may  be  estimated  by  determining 
the  amount  of  subluxation.  If  the  patient  lie  upon  the  well  side, 
and  a  line  (Nelaton's  line)  be  drawn  over  the  suspected  hip,  the 
thigh  being  somewhat  flexed,  from  the  anterior  superior  spine  to 
the  most  prominent  part  of  the  tuberosity  of  the  ischium,  it  should 
pass  just  above  the  upper  margin  of  the  trochanter;  if  the  trochan- 
ter is  above  this  line,  it  is  an  evidence  of  subluxation. 

The  amount  of  deformity  due  to  adduction  or  abduction  or  flex- 


////'  nrshiASii 


283 


ion  of  the  limb  is  an  important  index  of  the  progress  or  activity  of 
the  disease  and  should  be  carefully  estimated. 

Estimation  of  Adduction  and  Abduction. — This  estimation  of  the 
amount  of  adduction  or  abduction  present  has  ordinarily  been  made 
by  the  use  of  the  goniometer,  the  instrument  shown  in  the  figure. 
The  horizontal  arm  is  laid  on  the  anterior  superior  iliac  spines  and 
the  other  arm  is  then  laid  in  the  line  of  the  diseased  leg  and  the 
index  shows  the  angle  of  deformity.  This  instrument  is  clumsy 
and  inaccurate  and  not  always  at  hand.  A  simpler  method  has 
been  devised  by  which  it  is  possible  to  estimate  with  the  tape 
measure  alone  the  angle  of  either  abduction  or  adduction  present. 


Fig.  281.-  Goniometer. 

In  measuring  patients  it  is  found  that  real  and  practical  shorten- 
ing of  a  leg  are  often  not  the  same  in  the  same  patient,  and 
that  the  difference  between  them  varies  in  proportion  to  the 
amount  of  deformity  present.  This  was  taken  as  the  basis  for  con- 
structing the  following  working  table.  The  mathematical  pro- 
cess by  which  it  was  made  is  given  in  full  in  the  original  article,' 
the  results  are  all  that  concern  us  here.  To  measure  by  this 
method,  the  patient  is  made  to  lie  straight,  with  the  legs  parallel. 
Real  shortening  is  measured  with  the  ordinary  tape-measure,  and 
apparent  shortening  is  obtained  in  the  same  way.  It  may  be  re- 
'  R.  W.  Lovett,  Bost.  Med.  and  Surg.  Journal,  ]\Iarch  8th,  iSSS. 


284 


OR  THOPEDIC  S  URGER  V. 


peated  that  real  or  bony  shortening  is  measured  from  the  anterior 
superior  iliac  spines  to  each  malleolus,  and  that  practical  shorten- 
ing is  found  by  a  measurement  taken  from  the  umbilicus  to  each 
malleolus.  The  difference  in  inches  between  the  two  kinds  of 
shortening  is  seen  at  a  glance.  The  only  additional  measurement 
necessary  is  the  distance  between  the  anterior  superior  spines, 
which  is  taken  wath  the  tape.  Turning  now  to  the  table,  if  the  line 
which  represents  the  amount  of  difference  in  inches  between  the 
real  and  apparent  shortening  is  followed  until  it  intersects  the  line 
which  represents  the  pelvic  breadth,  the  angle  of  deformity  will  be 
found  in  degrees,  where  they  meet.  If  the  practical  shortening  is 
greater  than  the  real  sJiortening,  the  diseased  leg  is  addiictedj  if  less 
than  reed  shortening,  it  is  abducted.  Take  an  example :  Length 
(from  anterior  superior  spine)  of  right  leg,  23;  left  leg,  22^  ;  length 
(from  umbilicus)  of  right  leg,  25;  left  leg,  23;  real  shortening,  ^ 
an  inch,  apparent  shortening  2  inches ;  difference  between  real  and 
practical  shortening,  i^  inches;  pelvic  measurement,  7  inches.  If 
we  follow  the  line  for  i^  inches  until  it  intersects  the  line  for 
pelvic  breadth  of  7  inches,  and  we  find  12°  to  be  the  angular  de- 
formity, as  the  practical  shortening  is  greater  than  the  real,  it  is  12° 
of  adduction  of  the  left  leg. 


Distance  between  Anterior  Superior  Spi 

nes  in  inches. 

4 
i 
f 
I 

li 
li 
If 

2 

2i 
2i 
2f 

3 

3i 
3* 
3i 
4 

3 

3^ 

4 

4i 

5 

5i 

6 

b\ 

7 

1\ 

8 

8^ 

9 

9i 

10 

II 

12 

13 

5° 

4° 

4° 

3° 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

i" 

1° 

1° 

1° 

1° 

1-. 
0 

10 

8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

£/} 

14 

12 

II 

10 

8 

8 

7 

7 

6 

6 

5 

5 

5 

4 

4 

4 

3 

3 

1) 

19 

17 

14 

13 

II 

10 

9 

9 

8 

7 

7 

7 

6 

6 

6 

5 

5 

4 

Oh 

< 

25 

21 

iS 

16 

14 

13 

12 

II 

10 

9 

9 

8 

8 

7 

7 

7 

6 

6 

30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

II 

10 

10 

9 

9 

8 

7 

7 

"ca 

36 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

II 

10 

10 

9 

8 

8 

Pi 

42 

35 

30 

26 

23 

21 

19 

18 

16 

15 

14 

14 

13 

12 

12 

10 

ID 

9 

1) 
a; 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

II 

10 

Si 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

II 

0 

3S 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

42 

35 

32 

29 

27 

25 

23 

22 

21 

19 

18 

18 

16 

14 

13 

C 
1) 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15 

14 

40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17 

16 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18 

17 

42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19 

18 

////'    niSI'lASE. 


28s 


As  to  the  practical  accuracy  of  tlic  im.tliod :  it  has  been  used  by 
the  writer  and  others  in  a  larj^c  nimihcr  of  cases  of  hip-joint  dis- 
ease in  the  Surgical  Out-patient  Department  of  the  Children's 
Hospital,  and  afterward  a  very  careful  measurement  has  been 
taken  independently  with  a  fairly  accurate  goniometer,  and  the 
results  have  always  coincided  within  one  or  two  degrees. 

Estimation  of  Flexion. — The  flexion  deformity  of  the  thigh  may 
be  measured  by  a  similar  method.'  The  patient  lies  upon  a  table 
flat  on  his  back  and  the  surgeon  flexes  the  diseased  leg,  raising  it 
by  the  foot  until  the  lumbar  vcrtebr.x-  touch  the  table,  showing  that 
the  pelvis  is  in  the  correct  position.  The  leg  is  then  held  for  a 
minute  at  that  angle,  the  knee  being  extended,  while  the  surgeon 


'A  c 

Fig.  282. — Estimation  of  Flexion. 


measures  off  two  feet  on  the  outside  of  the  leg  with  a  tape  mea- 
sure, one  end  of  which  is  held  on  the  table  (so  that  the  tape  measure 
follows  the  line  of  the  leg)  (AB).  From  this  point  on  the  leg  (B) 
where  the  two  feet  reaches  by  the  tape  measure  one  measures  per- 
pendicularly to  the  table  (BC),  and  the  number  of  inches  in  the  line 
BC  can  be  read  as  degrees  of  flexion  of  the  thigh,  by  consulting 
Table  11.  For  instance,  if  the  distance  between  the  point  on  the 
leg  and  the  table  is  12}4  inches  it  represents  31°  of  flexion  deform- 
ity of  the  thigh. 

Table  II. 


In. 

Deg. 

In. 

De«. 

In. 

Deg. 

In. 

Deg. 

0.5 

I 

6-5 

16 

12.5 

31 

1S.5 

50 

I.O 

2 

7.0 

17 

130 

33 

19.0 

52 

1-5 

3 

7-5 

19 

13-5 

34 

19-5 

54 

2.0 

4 

S.o 

20 

14.0 

36 

20.0 

56 

2-5 

6 

8.5 

21 

14-5 

37 

20.5 

58 

3-0 

7 

9.0 

22 

15.0 

39 

21.0 

60 

3-5 

9 

9-5 

24 

15-5 

40 

21.5 

63 

4.0 

10 

lO.O 

25 

16.0 

42 

22.0 

67   » 

4-5 

II 

10.5 

27 

16.5 

43 

22.5 

70 

5-0 

12 

II. 0 

28 

17.0 

45 

23.0 

75 

5-5 

14 

II. 5 

29 

17-5 

47 

23-5 

So 

6.0 

15 

12.0 

39 

iS.o 

4S 

24.0 

90 

'  G.  L.  Kingsley  :    Bost.  I\Ied.  and  Surg.  Journ.,  Juh'  5th,  iSSS. 


286 


ORTHOPEDIC  SURGERY. 


If  the  leg  is  so  short  that  it  is  impracticable  to  measure  ojff 
twenty-four  inches,  one  can  measure  twelve  inches;  ascertain  from 
here  the  distance  to  the  surface  on  which  the  patient  is  lying  in  a 
perpendicular  line  in  the  same  way,  then  doubling  this  distance 
and  looking  in  the  table  as  before  the  amount  of  flexion  is  found. 

Thomas'  test  for  flexion  is  one  which  is  sometimes  of  use  for  a 
rough  estimation  of  the  amount  of  deformity.  The  patient  lies  on 
the  back  and  the  well  thigh  is  flexed  on  to  the  abdomen  and  held 
there.  This  places  the  pelvis  in  the  correct  position,  with  the  lum- 
bar spine  in  contact  with  the  table,  and  the  diseased  thigh  is  by  this 
naturally  thrown  into  a  position  of  flexion  if  such  deformity  exists. 


Fig.  283. — Thomas'  Test  for  the  Estimation  of  Flexion  of  the  Diseased  Leg  in  Hip  Disease. 

The  figure  makes  the  method  plain.  It  is  not  suitable  for  use  in 
cases  where  the  hip  is  sensitive,  nor,  as  a  rule,  in  the  case  of  adults. 

Atrophy. — Atrophy  of  the  muscles  is  an  early  symptom,  and  is 
determined  by  measuring  the  circumference  of  the  thigh,  or  by  in- 
spection or  palpation  of  the  muscles.  The  obliteration  of  the  fold 
of  the  buttock  mentioned  in  the  older  writers  is  due  to  this  atro- 
phy, but  it  is  not  always  one  of  the  earliest  symptoms.  The  mus- 
cular atrophy  is  greater,  as  a  rule,  than  that  of  simple  disuse  of  the 
muscles;  yet  in  the  earliest  cases  the  atrophy  may  be  so  slight  as 
to  escape  detection  by  the  tape  measure,  but  usually  it  rapidly 
becomes  more  marked  than  when  seen  in  simple  disuse,  as  is 
noticed  by  a  comparison  of  cases  of  hip  disease  with  cases  of  sim- 
ple motor  paralysis,  as  after  apoplexy  without  trophic  disturbance. 

The  measurement  for  atrophy  is  made  with  a  tape  measure  by 
taking  the  circumference  of  both  thighs  and  both  calves  at  the 
same  level  on  each  side.     In  cases  where  accuracy  is  desired,  the 


////'  nisF.ASE.  287 

level  at  which  the  circumference  is  t(j  be  taken  should  be  measured 
from  some  bony  point  on  both  sides,  such  as  the  anterior  superior 
spine,  the  patella,  or  the  malleoli,  to  insure  takin<r  the  measure- 
ment at  exactly  the  same  level.  The  conventional  places  for  such 
measurements  are  at  the  middle  of  the  thigh  and  the  middle  of  the 
calf.     The  absence  of  atrophy  does  not  exclude  hip  disease. 

Pain. — The  pain  in  well-marked  hip  disease  is  almost  invariably 
located  at  the  knee;  the  cause  of  this  is  not  certain,  but  has  already 
been  discussed.  Exceptionally,  the  pain  is  referred  to  the  leg  and 
follows  along  the  course  of  the  sciatic  nerve  ;  pain  located  at  the 
hip  instead  of  at  the  knee  is  usually  indicative  of  suppuration  or  the 
pressure  of  an  abscess  under  the  fascia;,  or  of  nervous  hyperaesthesia. 

Tenderness  on  jarring  the  hip  is  rarely  an  early  symptom.  Sen- 
sitiveness on  slight  jar  of  the  hip  is  sometimes  indicated,  previous 
to  the  presence  of  conscious  pain,  by  an  instinctive  wincing  on  the 
part  of  the  patient  if  the  limb  is  jarred.  The  use  of  violently  jar- 
ring the  hip  is  unnecessary  in  the  examination  of  a  patient  for  hip 
disease.  The  "  night  cries "  characteristic  of  hip  disease  have 
already  been  mentioned;  they  are  more  common  in  an  earlier  stage 
of  the  affection,  and  are  extremely  significant  in  pointing  to  the 
probable  existence  of  serious  joint  disease.  It  is  no  sign  of  the 
absence  of  hip  disease  when  one  is  able  to  suddenly  jam  the  head 
of  the  femur  into  the  acetabulum  without  causing  pain,  a  diagnos- 
tic method  sometimes  relied  on.  Its  violence  makes  it  unjustifiable 
as  well  as  untrustworthy. 

Swelling. — In  an  early  stage  of  hip  disease  there  is,  as  a  rule,  no 
swelling,  unless  the  affection  is  unsually  rapid  in  its  course ;  the 
glands  in  the  groin  may,  however,  be  found  to  be  enlarged  on 
palpation;  while  swelling  about  the  hip  is  not  uncommon  in  the 
later  stage  of  hip  disease.  Thickening  of  the  trochanter  major  is  a 
diagnostic  sign  of  some  assistance  when  present,  but  it  is  not  com- 
monly found  until  the  other  symptoms  are  so  fully  developed  as  to 
establish  the  presence  of  the  disease  without  its  aid.  To  recapitu- 
late the  important  symptoms  which  establish  the  diagnosis  of  hip 
disease,  they  are,  (i)  muscular  fixation,  (2)  lameness,  (3)  attitude 
and  shortening,  (4)  atrophy,  (5)  pain,  [6)  swelling. 

Differential  Diagnosis. 

A  few  affections  are  very  commonly  mistaken  for  hip  disease  in 
practice  and  deserve  extended  notice.'     These  are : 

'  Cox  :    Am.  J.  Med.  Sc,  April,  1S75,  p.  438.     J.  S.  Wight :    Arch,  of  Clin.  Surg., 
February,  1S77,  p.  283.     Wm.  Hunt  :  Am.  ].  of  Med.  Sci.,  January,  1S79,  p.  102.     Thos. 
G.    Morton:    Surgery   in   the    Pennsylvania  Hosp.,  iSSo.     J.  B.  Roberts:    Phila.    Med. 
Times,  i\ugust  3d,  1S78.     H.  L.  Taylor:    N.  Y.  Med.  Rec,  April  26th,  1SS4. 


288       .  ORTHOPEDIC  SURGERY. 

(i)  Lumbar  Pott's  disease. 

(2)  Synovitis  of  the  hip. 

(3)  Infantile  paralysis. 

(4)  Congenital  dislocation. 

(5)  Hysterical  affections. 

(6)  Peri-articular  affections. 

Other  affections  can  only  be  mistaken  for  hip  disease  through 
ignorance  of  its  proper  symptoms,  or  at  a  vei;y  early  stage  before 
the  symptoms  have  any  prominent  development. 

(i)  Lumbar  Pott's  disease  may  have  for  its  first  symptom  a  limp 
and  a  restriction  of  motion  in  one  leg.  This  is  due  to  the  descent 
of  pus  in  the  psoas  muscle  or  to  an  irritation  and  contraction  of  its 
fibres.  As  a  rule,  this  limited  motion  is  only  in  the  direction  of 
loss  of  hyper-extension,  but  it  may  take  the  form  of  a  general  re- 
striction of  motion  and  the  joint  may  be  sensitive  to  manipulation. 
The  point  to  be  determined  is  whether  rigidity  of  the  lumbar  spine 
is  present.  If  so  Pott's  disease  is  to  be  suspected  ;  but  sometimes 
in  hip  disease  at  a  sensitive  stage,  the  tenderness  of  the  joint  is  so 
great  that  on  attempted  manipulation  the  erector  spinae  muscles 
are  also  spasmodically  contracted  and  lead  to  the  appearance  of 
rigidity  of  the  lumbar  spine.  As  was  said  in  treating  of  Pott's  dis- 
ease, the  diagnosis  may  sometimes  be  a  very  difficult  one,  and  an 
opinion  must  be  withheld  and  the  case  kept  under  observation 
until  characteristic  symptoms  of  one  affection  or  the  other  develop. 
Later  in  the  history  of  lumbar  Pott's  disease  a  psoas  abscess  will 
often  descend  and  irritate  the  hip-joint  on  one  or  both  sides;  this 
may  again  so  closely  simulate  hip  disease  that  it  is  hard  to  tell 
whether  the  psoas  muscle  is  causing  all  the  trouble  or  whether  the 
joint  is  really  involved.  In  general,  however,  psoas  contraction 
only  causes  loss  of  hyper-extension,  and  loss  of  all  motion  at  the 
hip  is  a  very  suspicious  symptom,  which  will  pass  away  very  quickly 
•with  rest  and  quiet,  if  the  hip-joint  is  not  really  diseased. 

A  test  of  the  arc  of  abduction  of  the  hip  is  quite  a  valuable  one 
in  this  connection ;  as  this  motion  is  impaired  or  lost  at  a  com- 
paratively early  stage  of  hip  disease ;  but  even  in  well-marked 
cases  of  psoas  irritation  and  contraction  (without  inflammation  of 
the  hip-joint  proper)  abduction  often  remains  free.  In  making  this 
test,  however,  it  should  be  borne  in  mind  that  forcible  attempts  to 
abduct  the  limb  always  produce  resistance. 

(2)  Synovitis  of  the  hip  undoubtedly  occurs  in  children,  but  it  pre- 
sents the  symptoms  of  beginning  hip  disease  and  a  diagnosis  is 
not  practicable  in  the  early  stages  ;  and  the  fact  that  the  symptoms 
occur  after  a  fall  must  not  be  allowed  much  weight,  as  arguing  in. 
favor  of  synovitis. 


////'  j)isi':y\sh:.  289 

A  form  of  cnronic  subacute  synovitis  is  only  distinguishable  from 
true  hip  disease  by  the  relatively  briefer  course.  True  synovitis — 
in  distinction  from  ostitis — sometimes  begins  suddenly  without 
known  cause  with  exlieme  pain,  fever,  and  absolute  immobility  and 
local  swelling  of  the  hip,  the  limb  being  held  in  a  position  charac- 
teristic of  true  epiphyseal  ostitis.  These  symptoms  may  subside 
gradually  with  complete  recovery  of  the  joint.  In  some  instances 
the -recovery  is  quite  slow,  the  symptoms  lasting  months.  In  the 
acuter  forms,  lasting  but  a  few  weeks,  atrophy,  or  muscular  spasm, 
loss  of  electric  muscular  faradic  contractility  are  not  easily  recog- 
nized, though  judging  from  investigations  of  other  joints  affected  by 
acute  articular  rheumatism,  muscular  atrophy  and  impairment  of 
electrical  contractility  may  be  supposed  to  exist  in  acute  synovitis 
of  the  hip-joint. 

In  the  more  chronic  forms  of  synovitis  all  the  usual  joint  symptoms, 
such  as  atrophy,  muscular  spasm,  etc.,  may  be  present.  These  cases 
either  recover  or  develop  into  a  destructive  disease  of  the  joint, 
coming  to  autopsy  or  excision  and  a  verification  of  the  pre-existing 
synovitis  is  impossible.  In  one  instance,  however,  occurring  under 
the  observation  of  the  writer,  marked  symptoms  of  an  affection 
of  the  hip-joint,  including  stiffness,  limp,  pain,  muscular  atrophy 
and  spasm,  occurred  in  a  girl  of  ten,  who  died  of  an  intercur- 
rent pneumonia.  The  hip  symptoms  subsided  after  a  duration 
and  treatment  of  three  or  four  months,  the  motion  at  the  hip 
being  free  before  death.  At  the  autopsy  slight  evidence  of  syno- 
vitis was  found  in  a  portion  of  the  synovial  membrane  at  the 
junction  of  the  head  of  the  femur  with  the  capsule.  The  syn- 
ovial membrane  was  here  swollen  and  thickened  in  a  small  area, 
as  is  seen  in  the  conjunctiva  after  conjunctivitis,  the  rest  of  the 
joint,  the  ligamentum  teres,  the  cartilage  and  bone  on  section 
were  found  to  be  healthy.  In  brief,  it  may  be  said  that  in  cases 
with  marked  and  characteristic  symptoms  of  hip  disease,  where  re- 
covery takes  place  within  a  few  months,  it  may  be  inferred  that  no 
true  ostitis  existed. 

In  adults  hip  synovitis  comes  on  clearly  after  a  fall,  there  has 
been  no  preceding  disability,  muscular  spasm  is  present,  and  in 
time,  wasting  begins. 

Chronic  rheumatoid  arthritis,  morbus  coxae  senilis,  which  in 
many  cases  remains  purely  a  s}aiovitis  without  ostitis,  begins 
sometimes  idiopathically  without  the  history  of  even  slight  injury. 
The  chief  diagnostic  point  relates  alwa5^s  to  the  age  at  which  the 
patient  is  attacked,  it  being  practically  unknown  in  childhood,  ex- 
cept in  extensive  cases  where  other  joints  are  affected. 

(3)  At  the  stage  of  onset  of  infantile  paralysis  there  may  be  for 
^9 


290 


OR  THOPEDIC  S  URGER  V. 


a  short  time  in  rare  instances-  extreme  pain  and  tenderness,  with 
immobihty  of  one  Hmb ;  ordinarily  these  symptoms  are  not  accom- 
panied by  other  symptoms  of  hip  disease,  and  are  accompanied  by 
loss  of  power  of  the  rest  of  tlie  limb  as  well  as  a  loss  of  the  normal 
warmth  of  it,  rapidly  followed  by  atrophy  in  the  whole  limb.  In 
the  late  stages  of  infantile  paralysis  there  is  no  stiffness  at  the  hip- 
joint,  but  abnormal  mobility  in  all  directions  and  other  evidences  of 
infantile  paralysis,  such  as  distortion  of  the  foot  and  knee,  coldness, 
atrophy,  and  marked  loss  of  power  of  certain  muscular  groups 
which  make  an  error  in  diagnosis  impossible. 

Epiphyseal  Hypercemia. — Certain  cases  simulating  hip  disease 
may  be  assumed  to  be  due  to  epiphyseal  hyperaemia  of  a  compara- 
tively transient  character,  in  which  the  process  has  never  reached 
the  grade  of  degenerative  inflammation.  Such  cases  show  slight 
symptoms  of  hip  disease  and  especially  pain  on  motion.  The 
symptoms  subside,  and  permanent  recovery  soon  follows.  These 
are'  not  common  cases,  but  they  occur  at  times.  Unfortunately 
there  is  no  way  by  which  they  can  be  definitely  differentiated  from 
true  hip  disease. 

Bouilly  has  described  and  named  "  la  fievre  de  croissance,"  the 
symptoms  sometimes  seen  in  growing  children,  which  are  probably 
analogous  to  those  grouped  in  popular  language  under  the  head  of 
"  growing  pains."  Bouilly  is  inclined  to  classify  it  as  a  light  form 
of  osteo-myelitis  which  runs  its  course  without  suppuration,  and  is 
most  prevalent  at  the  time  of  the  most  rapid  growth.  It  is  sug- 
gested that  the  disease  is  characterized  by  a  faulty  circulation 
of  the  bones  caused  by  imperfect  development.' 

(4)  Congenital  Dislocation.- — Congenital  dislocation  of  the  hip- 
joint  need  not  be  mistaken  for  hip  disease,  as  the  clinical  history  of 
the  former  is  of  continued  limp  since  the  child  commenced  walking, 
while  in  hip  disease  the  limping  is  not  congenital.  There  are  also 
no  symptoms  of  muscular  stiffness  or  limitation  of  motion  of  the 
hip  in  congenital  dislocation,  in  fact  no  symptoms  of  hip  disease 
except  the  limp  in  gait.  Muscular  fixation  is  entirely  absent,  and 
the  mistake  only  arises  from  a  hasty  examination  or  an  ignorance 
of  the  symptoms  of  hip  disease. 

(5)  Hysterical  joint  affections,  as  they  are  to  be  diagnosticated 
from  organic  joint  disease,  will  be  considered  in  full  under  the  head 
of  functional  joint  disease.  It  maybe  said  here  that  the  symp- 
toms of  functional  and  organic  hip  disease  may  be  much  the  same. 
In  some  instances  in  the  former  a  temporary  relaxation  of  muscu- 
lar spasm  when  the  patient's  attention  is  diverted  is  noticed.     In 

'Vide    Tilling,  St.  Petersburg    Med.    Woch.,  1883,  No.    29.     Centralblatt  f.  Chir., 
1884,  No.  3. 


////'    D/S/wlSE.  291 

order  to  gain  evidence  of  this  fact  niucli  care  and  skill  is  sometimes 
required  in  examining  a  patient.  JJuring  the  usual  examination 
the  hip  may  be  found  very  stiff,  but  after  the  examination  is  com- 
pleted and  the  patient  is  dressed,  on  observation  it  will  be  seen 
that  considerable  motion  is  possible ;  although  the  patient  may  be 
unconscious  of  the  fact.  This  may  often  be  seen  in  the  attitude  of 
sitting,  moving  in  the  bed,  crossing  the  limbs,  buttoning  the  shoe, 
or  movements  which  in  organic  disease  of  the  joint  are  necessarily 
made,  not  only  with  difficulty,  but  in  such  a  way  as  to  indicate  ab- 
solute stiffness  at  the  joint.  For  a  positive  opinion  as  to  the  ab- 
sence of  organic  disease  in  a  doubtful  case,  repeated  examination 
is  often  necessary. 

A  very  troublesome  class  of  cases  is  where  the  real  and  func- 
tional joint  disease  are  present  in  the  same  joint.  In  these  cases 
the  symptoms  of  a  mild  coxalgia  are  so  exaggerated  by  the  patients 
that  to  all  appearances  the  case  is  a  most  serious  one,  whereas  the 
affection  may  be  very  slight  and  perhaps  convalescent.  The  true 
condition  in  these  troublesome  cases  can  only  be  reached  by  a 
careful  study  of  the  case  and  the  discovery  that  the  symptoms  are 
entirely  out  of  proportion  to  the  objective  signs.  This  exaggera- 
tion of  the  symptoms  of  hip  disease  is  not  uncommon  in  young 
women. 

It  may  be  supposed  that  an  anaesthetic  will  be  an  aid  in  the  diag- 
nosis of  hysterical  coxalgia,  as  the  muscular  spasm  of  both  hysteri- 
cal contraction  and  of  true  hip  disease  disappears  at  an  early  stage 
of  the  affection  under  an  anaesthetic ;  and  in  a  later  stage,  after  the 
muscles  have  become  permanently  shortened,  some  contraction  re- 
mains in  spite  of  an  anaesthetic.  It  is  true,  however,  that  there  is 
much  less  stiffness  under  an  anaesthetic  in  neuromimetic  coxalgia 
of  long  duration  than  in  true  hip  disease  with  active  inflammation 
and  osseous  changes ;  but  the  latter  can  ordinarily  be  recognized 
without  difficulty.  Sometimes  other  affections  may  be  mistaken 
for  hip  disease  and  the  brief  mention  of  a  few  additional  diag- 
nostic points  may  be  of  service. 

Hip  disease  is  so  very  often  diagnosticated  as  "knee  trouble" 
that  it  seems  worth  while  to  call  attention  to  the  well-known  fact 
that  hip-joint  pain  is  in  most  cases  referred  to  the  inner  side  of  the 
knee,  and  that  the  most  superficial  examination  will  show  which 
affection  is  present. 

It  has  been  said  that  perinephritis  and  perityphilitis  ma}-  be  mis- 
taken for  hip  disease.  Such  an  error  must  be  rare,  as  in  the  acute 
forms  these  affections  present  symptoms  much  more  severe  than 
are  presented  by  the  chronic  course  of  hip  disease.  In  the  chronic 
forms  of  these  affections   there  may  be  slight  psoas  contractions 


292  .  ORTHOPEDIC  SURGERY. 

and  the  presence  of  iliac  abscesses.  In  these  affections  the  Hmita- 
tion  to  motion  of  the  thigh  at  the  hip-joint  is  not  general  nor  does 
it  affect  abduction,  but  it  is  most  marked  in  the  direction  of  limita- 
tion of  extension. 

In  very  rare  instances  a  partial  rupture  of  the  adductor  muscles 
may  be  mistaken  for  hip  disease.  It  can  be  distinguished  by  the 
history  of  marked  violence  and  immediate  disability,  by  the  tender- 
ness of  the  adductor  muscles,  and  by  the  free  motion  of  the  hip  in 
the  direction  of  flexion  and  adduction. 

Peri-articular  disease,  which  has  not  yet  attacked  the  joint  or  the 
epiphyses  of  the  joint,  is  recognized  by  the  fact  that  the  inflamma- 
tion invading  certain  groups  of  muscles,  causes  a  limitation  to  mo- 
tion greater  in  one  direction  than  in  another,  while  the  limitation  to 
motion  in  disease  of  the  joint  is  equal  in  all  directions  of  normal 
motion  of  the  joint.  Under  the  head  of  periarticular  disease  may  be 
included  inflammation  of  bursas  and  lymphatic  glands,  psoas  abscess, 
or  psoas  muscular  spasm  from  caries  of  the  lumbar  spine  (psoitis). 
Sarcoma  of  the  hip  may  at  first  be  mistaken  for  hip  disease,  but 
there  is  greater  hardness  of  the  swelling  than  is  met  with  in  early 
hip  disease,  as  well  as  an  absence  of  the  usual  symptoms. 

A  separation  of  the  epiphysis  of  the  femur  at  the  hip  needs  here 
scarcely  more  than  mention,  it  is  a  rare  accident  occurring  only 
before  puberty,  and  the  symptoms  are  those  of  intercapsular  frac- 
ture of  the  neck  of  the  femur,  except  that  crepitus  is  not  present. 

Separation  of  the  epiphysis  from  the  diaphysis  may  occur  in 
juxta-epiphyseal  ostitis,  i.e.,  in  hip  disease.  It  would  be  recognized 
by  the  fact  that  the  trochanter  had  suddenly  become  much  higher 
on  the  affected  than  on  the  normal  side. 

Prognosis. 

The  prospect  which  every  surgeon  has  to  face  in  commencing 
the  treatment  of  hip  disease  is  not  an  encouraging  one.  He  natur- 
ally pictures  in  his  mind  the  number  of  patients  suffering  from  this 
disease  which  he  sees  in  the  hospital  wards  and  on  the  operating 
table.  His  attention  is  not  called  to  those  patients  who  after  they 
have  passed  from  the  hands  of  the  surgeon  or  from  hospital  clinics 
recover  with  more  or  less  deformity  to  enjoy  excellent  health 
throughout  life,  with  the  hindrance  only  of  a  limp  in  gait.  The 
fact  is  that  under  fairly  favorable  surroundings  the  disease  is  one 
which  tends  to  recovery  in  a  majority  of  cases  with  more  or  less 
deformity.  It  is  the  business  of  the  surgeon  to  see  that  chances  of 
recovery  are  as  favorable  as  possible,  and  when  recovery  occurs  that 
it  should  result  with  the  least  deformity  and  the  most  useful  limb. 


riip  nrsEASK, 


293 


The  accompanying  picture  will  illustrate  the  good  result  obtained 
in  a  case  of  average  severity.  It  is  that  of  a  young  man  of  twenty- 
eight  who  six  years  before  began  treatment  for  disease  of  the  hip- 
joint  which  had  been  developing  for  several  months  previous.  At 
the  time  treatment  was  begun  he  was  suffering  extreme  pain  at  the 
knee  and  sensitiveness,  with  the  usual  symptoms  of  acute  hip-joint 
disease.  The  condition  was  relieved  by  traction  and  confinement 
to  bed  for  nearly  a  year.     The  treatment  was  carried  on  according 


Fig.  285. 


Result  in  Hip  Disease. 


to  the  principles  mentioned  here,  and  at  the  end  of  a  year  he  was 
able  to  walk  about  using  crutches  and  wearing  a  traction  splint. 
The  latter  was  used  for  two  succeeding  years,  during  which  time  a 
threatening  abscess  appeared  in  the  thigh,  but  this  subsequently 
disappeared  without  evacuation.  The  following  year  he  used 
crutches,  but  was  finally  induced  to  discard  these  and  employ  a 
convalescent  splint,  having  experienced  an  acute  attack  on  at- 
tempting to  discard  all  support  of  the  hip.  With  the  aid  of  a  con- 
valescent splint  the  patient  was  enabled  to  engage  in  active  occupa 
tion,  to  walk  about  freely,  to  take  long  walks,  suffering  no  inter- 


294 


ORTHOPEDIC  SURGERY. 


ference  in  ordinary  occupations.  At  the  present  time,  six  years 
after  the  original  attack,  he  has  at  his  hip-joint  thirty  degrees  of 
motion.  No  deformity  is  present  and  no  shortening  of  the  affected 
hmb  and  no  noticeable  limp.  He  wears,  by  preference,  his  con- 
valescent splint,  but  is  able  to  take  short  walks  without  it. 

The  prognosis  of  hip  disease  is  to  be  considered  in  two  aspects: 
{a)  the  mortality  from  the  disease;  {b)  the  functional  results  to  be 
obtained  in  the  untreated  disease  and  under  the  different  modes  of 
treatment. 

(a)  Cazin  reports  that  in  80  cases  of  suppurative  hip  disease  treated 
at  the  hospital  at  Berck,  in  the  course  of  five  years,  fifty-five  per 
cent  were  cured;  twelve  and  one-half  per  cent  died;  twenty-five 
per  cent  were  not  cured  ;  seven  and  one-half  per  cent  were  im- 
proved when  removed.  Cazin  has  seen  recovery  in  desperate  cases. 
In  15  cases  of  suppurative  coxitis  with  albuminuria,  5  died  under 
conservative  treatment,  2  were  discharged  improved,  6  not  im- 
proved, 2  cured.'  These  cases  of  Cazin  were,  with  the  exception 
of  10,  severe  cases  sent  from  the  Paris  hospitals  after  they  had 
ceased  to  improve  there. 

Of  288  cases  collected  by  Gibney  there  was  a  mortality  of  twelve 
and  one-half  per  cent  from  exhaustion,  meningitis,  and  amyloid 
degeneration. 

In  the  Alexandra  Hospital,  London,  there  were  100  deaths  out 
of  384,  a  mortality  of  twenty-six  per  cent ;  of  these,  260  were  sup- 
purating cases,  and  the  death  rate  of  these  was  33.5  per  cent. 
Forty-two  per  cent  were  reported  cured. 

C.  F.  Taylor,  of  New  York,  has  reported  94  cases  Avith  only  3 
deaths  (i  by  accident),  and  with  recoveries  in  the  remainder;  of 
these  94,  24  were  suppurating;  and  of  these,  17  have  fully  re- 
covered. 

Dhourdin  reports  the  recovery  of  fifty-three  per  cent  in  237  cases 
of  acetabular  hip  disease. 

Hueter  reports  the  mortality  of  hospital  cases  at  twenty-seven 
per  cent,  and  Billroth  at  thirty-one  per  cent. 

Judson,  of  New  York,  in  describing  the  treatment  of  3  cases  of 
hip  disease  of  the  third  stage,  has  shown  what  can  be  done  by 
careful  treatment  of  these  cases. 

Shaffer  and  Lovett  investigated  51  cases  of  cured  hip  disease 
which  had  been  discharged  from  the  New  York  Orthopedic  Dis- 
pensary, at  least  four  years  previously,  and  found  that  41  had  re- 
mained cured.  Of  the  remaining  10,  4  had  died  and  6  had  relapsed, 
although  4  of  the  latter  had  been  apparently  cured  a  second  time.^ 

'  "  Statistique  des  Coxalgies  suppures,"  Bull,  de  la  Soc.  de  Chirurgie,  No.  5,  1876. 
^  N.  Y.  Medical  Journal,  May  21st,  1887. 


////'    DISEASE. 


295 


Yale,  after  considering^  carefully  all  the  statistics  bearing  on  the 
subject,  came  to  the  conclusion  that  the  mortality  from  hip  disease 
was  not  above  30^. 

Causes  of  Dcatli. — Death  may  occur  from  (i  j  the  generalization  of 
tuberculosis  in  the  form  of  phthisis,  tubercular  meningitis,  and 
general  tuberculosis.  (2)  From  amyloid  degeneration  of  the  vis- 
cera. (3)  From  exhaustion.  (4)  From  intercurrent  disease.  (5) 
From  septicccmia  and  exhaustion  after  su[)puration. 

In  a  more  recent  analysis  of  cases  at  the  Alexandra  Hospital 
made  since  1880,  the  number  of  instances  in  which  death  had  oc- 
curred as  the  result  of  the  disease  in  the  614  cases  that  had  been 
discharged  since  the  beginning  of  1880  {'jd  of  the  total  number  of 
690  being  still  in  the  hospital)  was  35.  Of  these  35  deaths  the 
causes  were  as  follows:  Meningitis,  12;  disease  of  the  lungs,  5; 
amyloid  disease,  9;  following  amputation,  3  ;  exhaustion,  2  ;  uncer- 
tain, 4. 

This  mortality  in  614  cases  amounts  to  nearly  6  per  cent,  the 
deaths  from  meningitis  to  a  little  under  2  per  cent,  and  from  tuber- 
culous disease  of  the  lungs  to  less  than  i  per  cent. 

It  is  interesting  to  compare  these  figures  with  those  in  the  Clini- 
cal Society's  Report  in  1880.  In  that  report  the  mortality  reached 
30.4  per  cent  in  the  suppurating,  and  about  7  per  cent  in  the  non- 
suppurating  cases,  the  deaths  from  meningitis  amounting  to  6  per 
cent.  Thus  there  is  a  great  reduction  of  mortality.  This  is  distrib- 
uted under  all  the  headings,  but  it  is  due  largely  to  the  diminu- 
tion under  the  head  of  amyloid  disease  and  exhaustion  in  the  sup- 
purating cases — a  result  attributable  to  the  improved  method  of 
treating  abscesses  by  early  incision  and  drainage. 

In  96  deaths  after  suppurative  hip  disease  at  the  Alexandra  Hos- 
pital, the  causes  were  as  follows : 


Meningitis,          ...... 

16.7^ 

Albuminuria  and  dropsy,  .... 

20.8 

Phthisis,      ....... 

5-2 

Phthisis  and  albuminuria, 

3-1 

Exhaustion,        ...... 

9.4 

Erysipelas  and  pyaemia,     .... 

3-1 

Intercurrent  disease,           .... 

7-1 

After  operation,         ..... 

9.4 

Unknown,           ...... 

25.0 

Spontaneous  recovery  has  occurred  in  some  extreme!}"  se\-ere 
cases  with  but  slight  treatment.  The  writer  can  record  a  case  of 
spontaneous  evacuation  of  the  necrosed  head  of  the  femur  followed 
by  recovery  and  a  useful  limb  with  some  motion  at  the  hip  and  but 


296  ORTHOPEDIC  SURGERY. 

one  and  one-half  inch  shortening.  This  result  followed  in  a  child 
of  seven,  but  little  treatment  except  the  use  of  crutches.  In  an- 
other case,  a  child  of  three,  treated  by  a  masseur  under  a  mistaken 
diagnosis,  spontaneous  dislocation  took  place  early  in  the  disease 
with  a  freely  movable  joint,  and  eventual  cure  with  but  little  short- 
ening. In  a  third,  an  infant  of  one  year,  after  suppuration  of  six 
months  the  head  of  the  femur  was  absorbed  and  a  loose  joint 
resulted  and  eventual  cure,  except  as  to  shortening  of  one  inch. 

In  the  matter  of  the  prognosis  of  functional  results  to  be  ob- 
tained there  is  fortunately  more  definite  information  at  hand.  As 
to  the  expectant  method  in  1878  Dr.  Gibney'  reported  80  cases 
which  were  cured  at  the  Hospital  for  the  Ruptured  and  Crippled  in 
New  York,  by  internal  medication  and  counter-irritation.  Abscesses 
had  existed  in  48  cases,  and  in  the  other  32  cases  there  was  present 
no  abscess.  At  the  end  of  the  disease  (which  in  33  cases  ran  its 
course  in  3  years,  in  28  cases  in  from  3  to  6  years,  and  in  19  cases 
from  6  to  10  years),  61  of  these  patients  could  walk  well,  and  run 
without  discomfort;  12  walked  only  fairly,  requiring  a  support  at 
times  ;  and  7  could  not  walk  without  crutches.  Of  these  80  cases, 
12  had,  at  least,  an  arc  of  15  degrees  motion  in  the  affected  joint, 
the  amount  of  shortening  being,  in  .the  majority  of  cases,  from  i  to 
3  inches. 

Better  results  were  obtained  in  the  series  of  51  cases  investigated 
at  the  New  York  Orthopedic  Dispensary  and  Hospital,  where  only 
conservative  treatment  was  employed.  Of  the  41  cases  who  re- 
mained well  (out  of  the  51  discharged  cured)  none  were  incapaci- 
tated from  doing  a  full  day's  work  at  his  or  her  trade  or  occupation. 
Only  one,  a  boy  who  had  suffered  from  both  Pott's  disease  and  hip- 
joint  disease,  used  a  cane,  and  none  used  crutches.  There  were 
among  those  who  recovered,  printers,  glaziers,  machinists,  errand- 
boys,  shop-girls,  dress-makers,  and  many  children  attending  the 
public  schools — all  at  their  work  and  none  with  evidences  of  active 
tubercular  disease  or  any  serious  incapacity  arising  from  the  con- 
dition for  which  they  were  treated  years  before. 

Under  conservative  treatment  carried  out  for  a  sufficient  time  one 
may  expect  a  good  functional  result  in  the  majority  of  cases.  In 
few  diseases  is  the  benefit  of  thorough  and  long-skilled  continued 
treatment  more  clear,  and  in  few  surgical  affections  can  the  surgeon 
attempt  to  check  the  progress  of  disease  and  influence  recovery 
with  greater  probability  of  success  than  in  hip  disease ;  but  the 
surgical  care  and  supervision  should  not  be  limited  to  the  more 
acute  stages  of  the  affection,  but  should  be  continued  during  the 
convalescent  stage  if  the  best  results  are  desired. 
'  New  York  Med.  Rec,  March  2d,  1878. 


II  IP   DISK  ASK. 


297 


A  recent  investigation  has  been  made  by  Howard  Marsh'  of  the 
results  of  the  conservative  treatment  of  hip  disease  as  practised  at 
the  Alexandra  Hospital  which  shows  the  favorable  results  to  be 
obtained  by  mechanical  treatment  (fixation).  Of  37  cases  (where 
suppuration  had  occurred)  at  the  end  of  i  year  after  discharge 
I  was  a  perfect  recovery. 

6  were  excellent. 
17  were  good. 

13  were  moderate. 

3  hajd  no  shortening. 

17  had  under  one  inch. 

12  had  between  i  and  2  inches. 
3  had  2  inches  or  over. 

I  had  perfect  movement  in  every  direction. 
10  had  free  movement. 

7  had  slight  movement. 

18  were  fixed. 

The  39  cases  which  did  not  suppurate  went  on  to  still  better 
results.     There  were 

9  perfect  recoveries. 
9  excellent        " 
12  good  " 

9  moderate        " 

and  the  average  amount  of  shortening  was  two-thirds  of  an  inch, 
while  50^  had  what  Mr.  Marsh  classed  as  "  free  movement." 

These  are  excellent  results  from  any  treatment,  and  if  such  evi- 
dence were  needed,  speak  strongly  in  favor  of  thorough  and  per- 
:sistent  conservative  treatment.  In  all  cases  the  treatment  pursued 
was  a  bed  extension  and  Thomas  splint. 

LeyigtJi  of  Time  for  Treatment. — In  general  the  disease  does  not 
present  the  appearance  of  absolute  recovery  without  probability  of 
relapse  in  well-marked  cases  under  two  or  three  years  of  treat- 
ment, and  it  is  best  to  continue  protection  to  the  joint  beyond 
that  time.  The  following  table  gives  the  length  of  time  that  the 
cured  cases  reported  by  Shaffer  and  Lovett  were  under  treatment. 

Table   Showing  Length  of  Time  Under  Treatment. 


2  years 4  cases. 

2^  years 4 

3  years g     • ' 

3|-  years 6     " 


4  years    S  cases. 

4^  years 2     " 

5  years 2     " 

6  years i  case. 


b\  years i  case. 

7  years i    '  * 

8  years i    " 

Total 39  cases. 


'  British  Med.  Journ.,  August  3d,  1SS9. 


298 


ORTHOPEDIC  SURGERY. 


It  may  be  stated  that  from  two  to  three  years  will  probably  be 
needed  in  the  treatment  of  a  case  of  hip  disease  taken  at  an  early 
stage. 

The  early  discontinuance  of  treatment  is  a  serious  mistake,  as  re- 
lapses are  likely  to  occur  when  everything  seems  quiet.  Again 
and  again  it  has  been  the  experience  of  the  writers  to  change  to  a 
convalescent  splint  in  cases  where  the  symptoms  had  been  thor- 
oughly quiescent  for  months  and  the  change  has  been  followed  by 
a  relapse  within  a  few  weeks.  In  the  same  way  too  early  a  discon- 
tinuance of  the  convalescent  splint  will  often  cause  trouble.  It  is, 
therefore,  much  safer  to  err  on  the  side  of  keeping  an  apparatus 
unnecessarily  long  than  to  run  what  would  seem  to  be  a  considera- 
ble risk  of  relapse. 

The  prognostic  value  of  certain  symptoms  can  well  be  considered. 

Muscular  Fixation,  or  muscular  rigidity,  disappears  as  the  disease 
improves  and  motion  returns  to  the  diseased  joint.  It  may  return 
entirely  and  the  presence  or  absence  of  abscess  does  not  affect  the 
outlook  in  that  regard,  as  shown  in  this  table  from  the  Orthopedic 
Dispensary  series. 

Table  Showing  the  Influence  of  the  Presence  or  Absence  of 
Abscess  upon  Ultimate  Joint  Motion. 


Condition  of  Joint  as  regards  Motion. 

One  or  More 
Abscesses. 

No  Abscess. 

Total. 

Cases. 

12 

4 

5 
3 
2 

Cases. 

4 
2 
2 

I 

Cases. 
16 

6 

7 
3 
3 

Perfectly  free  motion 

The  amount  of  motion  diminishes  after  the  cessation  of  treatment. 

If  a  cure  with  ankylosis  takes  place,  an  important  practical  point, 
as  regards  the  use  of  the  limb  and  locomotion,  is  the  position  in 
which  ankylosis  occurs.  In  15  of  the  cases  alluded  to  where  there 
was  little  or  no  motion  at  the  articulation,  there  was  no  flexion  of 
the  thigh.  The  limp  in  these  cases- was  trivial.  In  other  cases  the 
thigh  was  flexed  at  an  angle  of  120°  to  135°  with  the  horizontal 
plane  of  the  body.  This  was  not  a  serious  impediment  to  locomo- 
tion when  a  flexible  dorso-lumbar  spine  and  a  sound  hip-joint  on 
the  opposite  side  existed,  but  in  one  case  there  was  caries  of  the 
lumbar  spine,  and  in  this  case  there  was  very  difificult  locomotion. 
Flexion  to  135°  with  a  normal  spine  does  not  produce  either  diffi- 
cult locomotion  or  a  bad  gait,  and  in  no  case  examined  did  the 
permanent  flexion  exceed  this  angle. 


////'  nisEAsi':.  299 

Permanent  adduction  is  a  more  imi)ortant  matter.  Of  24  cases  it 
was  very  slight  or  absent  in  13,  in  8  it  equalled  lo'"  to  \^'%  and  in  3 
cases  it  was  about  30".  In  two  cases  there  was  slight  abduction  of 
the  thigh,  and  in  one  of  these  there  was  a  condition  of  superexten- 
sion of  the  knee.  But  even  in  this  condition  the  patient  walked 
well.  In  cases  where  abduction  was  present  in  the  earlier  history 
of  the  disease,  adduction  was  found  in  the  late  history;  and  adduc- 
tion is  likely  to  occur  after  the  removal  of  the  splint,  and  to  in- 
crease up  to  a  certain  point.  But,  as  shown  above,  adduction  to 
30°  occurred  in  only  three  cases,  and  in  only  one  of  these  was  it 
troublesome.  In  this  case  the  slight  flexion,  with  adduction  to  30''% 
a  real  shortening  of  one  inch  and  a  half  became,  for  the  practical 
purpose  of  locomotion,  a  shortening  of  four  inches. 

The  prognosis  as  to  distortion,  however,  does  not  necessarily 
imply  permanent  distortion;  for  at  the  present  time,  after  recovery 
from  hip  disease  (the  deformity  still  existing  with  severe  flexion 
and  adduction)  these  disfigurements  can  be  entirely  and  perma- 
nently relieved  by  subtrochanteric  osteotomy.  In  short,  by  far  the 
greater  number  of  cases  of  this  distortion  can  be  prevented  by 
ordinary  care  and  thorough  treatment.  If  they  continue  after  the 
disease  at  the  hip  is  cured,  the  deformities  can  be  overcome  with 
but  slight  risk,  by  means  of  operative  interference. 

It  is,  however,  much  more  desirable  to  correct  malposition  of 
the  limb  whenever  it  occurs  than  to  allow  it  to  become  permanent 
when  its  correction  is  a  much  more  serious  matter.  The  prognosis 
as  to  lameness  has  already  been  alluded  to  in  speaking  of  the 
amount  of  malposition  of  the  limb. 

Some  sJiortening  will  be  in  a  majority  of  cases  present  if  the  dis- 
ease continues  for  anytime;  but  for  practical  use  in  locomotion 
the  actual  shortening  is  of  much  less  moment  than  position  of 
the  limb. 

In  the  Orthopedic  Dispensary  series  the  difference  in  the  length 
of  the  legs,  measured  from  the  anterior  superior  spine  of  the  ilium 
to  the  inner  malleolus,  was,  when  any  difference  existed,  from  half 
an  inch  to  two  inches  and  a  half,  with  two  exceptions.  One  patient, 
with  dislocation  of  the  head  of  the  femur,  had  six  inches  shorten- 
ing, and  one  (without  abscess)  had  three  inches.  Two  had  abso- 
lutely no  shortening.  The  case  with  six  inches  shortening  and  dis- 
location ran  its  entire  course  without  evidences  of  suppuration, 
while,  on  the  other  hand,  the  patients  in  whom  there  was  absolutely 
no  shortening  each  had  abscesses.  It  will  be  seen  from  a  study 
of  the  following  table,  however,  that  the  cases  where  abscess  was 
present  show  more  shortening  than  the  others: 


300 


ORTHOPEDIC  SURGERY. 


Table  Showing  Relation  of  the  Presence  or  Absence  of 
Abscess  to  Shortening  of  the  Limb. 


Shortening,  in  Inches. 

Cases  without  Abscess. 

Cases  with  Abscess. 

2 

I 

5 
4 

8 

5 

a 

I 

I 

5 

3 
I 

li 

2 

2\ 

3 

I 

6 , 

I 

Total   

25 

12 

The  shortening  increases  slightly  in  after-years,  that  is,  the  dis- 
eased leg  receives  a  permanent  retardation  of  growth  as  compared 
to  the  healthy  limb. 

Actual  shortening  due  to  arrest  of  growth  of  the  limb  is  beyond 
the  control  of  the  surgeon;  but  shortening  from  subluxation  or 
dislocation  of  the  head  of  the  femur  or  enlargement  of  the  acetab- 
ulum may  be  said  to  be  due  to  a  lack  of  thoroughness  of  treat- 
ment. Perfect  treatment  may  in  some  instances  be  impossible, 
from  circumstances  beyond  the  control  of  the  surgeon;  but  he 
should  persistently  bear  in  mind  that  subluxation  and  distortion 
can  be  prevented  by  thorough  treatment  of  the  disease. 

Atrophy  is  never  entirely  cured,  but  in  the  calf  muscles  it  dimin- 
ishes very  much  after  the  use  of  the  leg  is  resumed. 

The  significance  of  abscess  is  not  very  great;  it  has  been  seen  that 
it  does  not  affect  the  ultimate  amount  of  motion  in  the  joint  nor 
does  it  seriously  increase  the  shortening.  When  abscesses  occur 
in  cases  under  careful  mechanical  treatment,  the  outlook  is  worse 
than  in  suppurative  hip  disease  in  general,  because  the  careful  treat- 
ment prevents  the  occurrence  of  abscess  in  all  but  the  worst  cases, 
so  that  in  these  the  death  rate  is  necessarily  high.  In  a  series  of 
63  cases  from  the  Boston  Children's  Hospital'  the  death  rate  was 
.40^,  but  abscess  only  occurred  in  23^  of  all  cases  of  hip  disease 
under  out-patient  treatment,  whereas  the  earlier  Alexandra  reports 
gave  70^  of  abscesses  ;  if,  therefore,  abscess  appears  in  spite  of 
careful  treatment  and  preventive  measures  its  prognostic  import 
is  unfavorable. 

Pain, — The  amount  of  sensitiveness  of  the  hip  and  pain  in  cases 
which  are  well  treated  should  be  slight,  though  nocturnal  cries  miay 
persist  for  a  while  in  the  early  stages.  The  re-occurrence  of  night 
•cries  late  in  the  disease,  or  of  acute  sensitiveness  of  the  joint,  is 

^  Boston  Med.  and  Surg.  Journ. ,  Nov.  2ist,  1889,  p.  503. 


Jlir    DISI'-.ASE. 


301 


most  often  a  sign  of  inadequate  treatment  or  of  trouble  coming  in 
the  joint;  but  most  frequently  it*  j)recedcs  the  occurrence  of  ab- 
scess. 

Treatm  i:nt. 

The  treatment  of  hip-joint  disease  is  of  the  greatest  importance, 
and  has,  therefore,  received  much  attention  from  surgeons,  espe- 
cially at  the  present  time.  Many  conflicting  theories  have  been 
advanced  and  different  methods  advocated,  which  demand  careful 
consideration.  The  principles  of  treatment  of  chronic  disease  of 
all  joints  remain  the  same,  but  certain  variations  necessarily  foljfjw 
the  different  anatomical  conditions  of  joints,  and  the  hip  is  to  be 
treated  practically  in  a  difTerent  way  than  would  be  possible  in  the 
elbow,  ankle,  or  temporo-maxillary  joint.  It  should  be  borne  in 
mind  that  where  ostitis  of  the  bones  of  the  joint  exists,  all  jar  or 
exaggerated  pressure  or  violent  motion  of  the  joint  is  to  be  pre- 
vented, and  if  synovitis  is  present  at  an  acute  stage  all  motion  is  to 
be  avoided,  and  in  a  subacute  condition  only  guarded  motion  should 
be  allowed.  Treatment  will  necessarily  vary  according  to  the  stage 
of  the  disease  and  the  pathological  condition  present. 

Treatment  may  be  classified  as  conservative  and  operative. 

The  Conservative   Treatment  of  Hip  Disease. 

The  indications  in  treatment  of  hip  disease  are  to  furnish  sever- 
ally, fixation,  traction  (extension),  and  protection ;  to  benefit  the 
patient's  general  condition,  to  prevent  and  correct  deformity,  to 
allow  locomotion  as  far  as  is  compatible  with  the  surgical  indica- 
tions, and  to  meet  such  complications  (peri-articular  inflammation, 
abscess,  and  sequestra)  as  may  arise.  Treatment,  it  is  manifest, 
should  be  adapted  so  that  it  can  be  continued  not  only  during  the 
active  and  subacute  stages  of  the  disease,  but  also  during  the  con- 
valescent period,  and  until  the  affected  joint  is  able  to  stand  the 
jars  incident  to  locomotion  without  fear  of  recurrence  of  the  dis- 
ease. 

Fixation. — The  means  generally  used  for  fixation  are:  i.  Plaster- 
of-Paris  bandages,  or  leather  and  metal  splints  applied  to  the  hip, 
pelvis,  and  thigh,  for  fixation.  2.  The  Thomas  splint.  3.  Gout- 
tiere  de  Bonnet's  "wire  cuirass,"  or  some  modification  of  it. 

Plaster  bandages  furnish  an  imperfect  form  of  fixation,  as  they 
do  not  firmly  hold  the  trunk  above  the  pelvis,  and  owing  to  the 
possible  motion  of  the  lumbar  vertebrae,  the  pelvis  is  able  to  move 
within  the  bandage,  allowing  motion  at  the  acetabulum  and  dietor- 


?02 


ORTHOPEDIC  SURGERY. 


tion  of  the  limb.  A  plaster-of-Paris  bandage  for  fixation  of  the 
hip  is  usually  applied  as  a  spica  running  down  to  the  knee  or  be- 
low it  and  running  upward  to  take  some  hold  upon  the  thorax. 

The  amount  of  fixation  furnished  by  a  plaster-of-Paris  bandage 
can  be  made  as  great  as  possible  by  applying  the  bandage  to  the 
well  limb  as  well  as  the  affected  one,  and  continuing  it  well  upward 
on  to  the  thorax;  but  motion  in  the  lumbar  region  is  possible  even 

under  these  circumstances,  and  no 
direct  check  is  given  to  the  increased 
intra-articular  pressure  from  muscu- 
lar spasm.  Furthermore  the  method 
is  a  clumsy  and  uncleanly  one.  It 
will,  however,  be  sometimes  found 
of  use  in  unruly  children  or  where 
the  nursing  is  imperfect  and  the  joint 
is  sensitive.  The  most  convenient 
way  is  to  anaesthetize  the  patient  if 
any  distortion  is  present,  which 
should  be  corrected,  and  a  plaster-of- 
Paris  splint  applied.  This  method 
of  treatment  is  only  to  be  employed 
as  a  temporary  measure,  and  is  not 
satisfactory  when  continued  over 
any  length  of  time.  When  distor- 
tion of  the  limb  is  present  and  it  is 
not  expedient  to  etherize  the  pa- 
tient, the  bandage  should  be  ap- 
plied to  the  limb  in  its  distorted 
position.  The  fixation  will  have 
such  a  quieting  effect  upon  the  mus- 
cles that  at  the  next  application  of 
a  bandage  it  will  be  found  possible 
to  place  the  limb  in  a  much  better 
position. 

What  has  been  said  of  the  plaster-of-Paris  spica,  even  when  so 
applied  as  to  hold  the  thorax  and  the  other  leg,  is  true  of  metal 
and  leather  splints,  which  do  not  so  completely  hold  the  joint  as 
that  does.  These  lack  fixative  power  by  virtue  of  the  little  hold 
which  they  have  upon  the  pelvis,  and  although  in  many  cases  of  hip 
disease  they  serve  every  therapeutic  purpose  in  acting  as  an  incom 
plete  means  of  fixation,  they  cannot  be  advocated  for  general  use. 
It  can  be  seen  from  a  glance  at  Figures  287  and  288  how  little  hold 
upon  the  pelvis  such  a  splint  can  have.  Dr.  Vance's  splint  is 
better  in  taking  a  better  hold  of  the  thorax  than  most  of  them  do, 
and  affords  fair  fixation. 


Fig.  286. — Plaster  of  Paris  Bandage  ap- 
plied for  Fixation  of  the  Right  Hip. 


////'    DISh'.ASE. 


303 


TJic  Thomas  Splint. — The  Thoiiias  liip  splint,  invented  by  Mr.  II. 
O.  Thomas,  of  Liverpool,  is  an  appliance  in  use  in  England.     It  is  a 


Fig.  2S7.-  Fixation  Sp'.int  for  Hip  Disease.  f,g_  288.— Vance's  Leather  Splint. 

I'ixation  Splint  for  Hip  Disease. 


very  simple  apparatus,  easily  made,  and  having  many  points  of 
usefulness.  It  consists  of  an  iron  bar  extending  from  the  inferior 
angle  of  the  scapula  to  a  little. above  the  ankle;  the 
upper  end  of  which  is  attached  to  a  chest  piece 
which  is  at  right  angles  to  the  upright  and  encir- 
cles the  chest,  fastening  in  front.  There  are  two 
circlets  of  iron  which  grasp  the  thigh  and  calf. 
The  appliance  is  kept  in  place  by  a  wide  chest  band 
and  a  bandage  around  the  limb,  and  can  be  bent  to 
fit  any  degree  of  flexion  existing  in  the  diseased 
leg  and  applied  to  it  in  that  position.  The  apparatus 
requires  much  skill  in  adjustment,  as  it  is  hard  to 
fit  and  keep  in  place.  In  Mr.  Thomas's  hands  it 
is  undoubtedly  an  efficient  instrument,  but  an  ex- 
tended and  careful  use  of  the  splint  by  the  writers, 
in  many  cases  under  all  sorts  of  conditions,  has  led 
them  to  a  preference  for  other  methods  of  treat- 
ment. A  Thomas  splint  cannot  be  said  to  furnish 
complete  fixation,  nor  does  it  prevent  the  occur- 
rence of  subluxation,  or  counteract  the  spasmodic  muscular  con- 
traction  of  the  muscles  connecting  the  lower  extremity  with  the 


FiG.  cSq. — Hip  Splint 
Single. 


304 


ORTHOPEDIC  SURGERY. 


pelvis,  so  important  a  feature  in  hip  disease.  The  appliance,  how- 
ever, prevents  motion  of  any  great  amount,  enables  the  patient  to 
be  lifted  without  jarring  the  hip,  and  prevents  and  corrects  flexion 
of  the  thigh.  In  certain  acute  cases  the  pain  may  be  increased  by 
the  Thomas  splint,  from  the  fact  of  the  imperfect  fixation  fur- 
nished. For  inasmuch  as  the  leg  and  thigh  are  firmly  held  by  the 
appliance,  i.  e.,  the  flat  rod  to  which  they  are  bandaged,  and  this 
rod  extends  up  the  trunk,  it  cannot  be  so  firmly  fixed  to  it  but 


Fig.  290. — The  Thomas  Splint  Applied.  Front  view.     Fig.  291. — The  Thomas  Splint  Applied.  Posterior  view^ 

that  some  motion  is  possible  at  its  upper  end,  as  the  patient  turns 
in  bed  or  moves.  Motion  of  the  upper  end  of  the  rod  is,  of  course, 
communicated  to  the  lower,  and  the  joint  may,  in  this  way,  be 
twisted  and  jarred  by  the  long  lever  attached  to  the  thigh. 

Where  deformity  exists,  the  splint  is  necessarily  not  as  efificient 
as  a  means  of  fixation  as  when  deformity  has  been  corrected  ;  the 
appliance  can  be  made,  however,  an  efficient  means  of  correction 
of  deformity.  A  double  Thomas  splint  is  more  efficient  as  a  means 
of  fixation,  but  it  does  not  easily  permit  locomotion ;  in  a  single 
Thomas  splint  a  raised  patten  is  put  under  the  shoe  of  the  well  foot 
and  crutches  are  used.      This  appliance  certainly  furnishes  a  ready; 


////'  JJJSEASJC. 


y^s 


and  fairly  efficient  means  of  treatment  of  hip  dis- 
ease in  the  acute  and  subacute  stage. 

A  substitute  for  the  Thomas  splint,  made  oi 
stout  iron  wire,  introduced  by  Dr.  A.  T.  Cabot,  of 
Boston,  will  be  found  of  use  in  the  case  of  smaller 
children,  and  by,  its  means  the  limb  can  be  more 
readily  fixed  than  by  the  ordinary  Thomas  splint. 
This  is  practically  a  posterior  wire  splint  to  the 
trunk  and  affected  limb.  P4!ade  of  stout  iron 
wire  it  can  be  easily  bent  to  fit  any  case,  and  is 
covered  with  canton  flannel  after  the  wire  has 
been  wound  with  sheet  wadding.  A  body  swathe 
holds  the  upper  part  of  the  splint  in  place  and  the 
leg  is  bandaged  to  it.  For  young  children  with 
flexion  of  the  leg  it  is  an  admirable  splint,  but  it 
fails  to  perfectly  fix  the  limb  when  used  in  older  ones,  y^c. 
for  the  reason  that  it  is  almost  impossible  to  make 
the  body  swathe  hold  the  trunk  firmly  in  place. 

Wh'e  Cuirass. — The  gouttiere  de  Bonnet,  or 
wire  cuirass,  furnishes  excellent  fixation.'  It  is, 
however,  cumbersome  and  expensive,  and  has 
the  defect  of  not  thoroughly  giving  the  benefit 
which  can  be  afforded  by  traction  in  relieving 
the  increased  intra-articular  pressure,  unless  fur- 
nished with  arrangements  for  traction  and  coun- 
ter traction. 


292. — Thomas' Hip 
Splint,  Double. 


Fig.  293. — Cabot's  Posterior  Wire  Splint  for  Treatment  of  Hip  Disease. 


Fig.  204. — The  Wire  Cuirass. 


'  For  a  modified  and  improved  wire  cuirass,  see  Nicaise,  Rev.  de  Chin,  Jan.  loth,  'SS. 
20 


3o6 


ORTHOPEDIC  SURGERY. 


Dr.  Phelps,  of  New  York,  has  shown  a  most  excellent  method  of 
fixation  by  means  of  a  readily  made  fixation  appliance  illustrated 
in  the  accompanying  picture/     Fixation  in  this  way  is  a  method  of 


Fig.  295. — Phelps's  Fixation  Appliance. 


^  N.  Y.  Med.  Rec,  March  4th,  18 


////'   D/S/CASE.  .    •  307 

treatment  common  in  France,  and  i.s  excellent  in  the  more  acute 
stages  of  the  disease.  The  patients  can  be  carried  about  readily 
without  fear  of  jar  or  injury  to  the  hip, 

I inmobilizat ion  and  Ankylosis. — With  regard  to  the  immobilization 
of  a  diseased  hip-joint  much  has  been  written  in  reference  to  the 
danger  of  ankylosis  thereby  incurred.  This  subject  was  quite  fully 
discussed  before  the  Society  of  Surgery  in  Paris  in  1879. 

M.  Verneuil,  in  an  able  paper,  stated  as  his  opinion  that  the 
dread  of  ankylosis  leads  surgeons  to  a  great  deal  of  bad  practice. 
He  opposes  this  "  ankylophobia "  and  the  practice  of  passive 
motion,  and  he  denies  that  a  single  fact  can  be  cited  in  the  whole 
science  of  surgery  to  prove  that  prolonged  and  continued  rest  has 
caused  ankylosis  of  a  healthy  joint.  Certain  experiments  have 
shown  that  absolute  rest  has  caused  a  thinning  and  alteration  of 
the  cartilages  of  the  joint,  a  limitation  to  motion,  a  diminution  of 
the  amount  of  synovial  fluid;  but  these  experiments  and  the  autop- 
sies which  are  quoted  he  does  not  consider  convincing,  or  suffi- 
ciently reliable  to  counterpoise  the  testimony  of  many  cases  of 
perfect  recovery  of  motion  after  prolonged  rest.  In  diseased  joints 
ankylosis  sometimes  occurs  after  prolonged  rest;  but  this  Verneuil 
thinks  is  not  a  result  of  the  treatment,  but  in  spite  of  it.  Anky- 
losis is  due  to  the  contraction  of  the  periarticular  muscles,  reflex 
from  the  irritation  at  the  joint.  He  makes  a  distinction  between 
mechanical  rest  produced  by  devices  for  immobilization  and  that 
which  is  produced  by  the  action  of  the  surrounding  muscles.  This 
latter  is  in  the  end  destructive  to  a  joint,  and  the  tendency  of  this 
muscular  spasm  is  to  increase  the  pressure  of  the  diarthrodial  sur- 
faces. The  former  is  effective  in  diminishing  muscular  contrac- 
tions and  the  destructive  changes  which  accompany  them. 

Methods  of  Treatment  by  Traction. — All  the  above  methods  of  at- 
tempted fixation  overlook  the  injurious  influence  of  muscular  spasm 
of  the  muscles  about  the  hip,  in  spasmodically  jarring  the  hip- 
joint,  and  in  exerting  an  undue  pressure  by  crowding  the  inflamed 
epiphysis  of  the  femur  against  the  acetabulum.  This  reflex  spasm 
of  the  muscles  about  a  joint  is  constant  in  all  inflamed  joints  sur- 
rounded by  muscles,  and  it  is  of  especial  importance  in  hip  disease, 
from  the  strength  of  the  muscles  about  the  joint.  Such  spasm 
prevents  rest  of  the  joint,  increases  the  pressure  on  the  inflamed 
bone,  causes  distortion  of  the  limb,  absorption  of  the  head  of  the 
femur,  enlargement  of  the  acetabulum,  and  subsequent  subluxa- 
tion of  the  femur.  The  force  of  the  pressure  can  be  estimated  if 
we  consider  the  great  strength  of  the  muscles  extending  from  the 
pelvis  to  the  femur.  A  sudden  spasmodic  contraction  of  all  these 
muscles  drives  the  head  of  the  femur  against  the  acetabulum  with 


3o8  ORTHOPEDIC  SURGERY. 

the  force  of  a  sharp  blow,  and  unless  this  is  overcome,  no  attempt 
at  securing  rest  of  the  joint  is  complete. 

To  antagonize  as  far  as  possible  this  injurious  muscular  force,  a 
pull  upon  the  femur  away  from  the  acetabulum  is  necessary.  This 
is  often  instinctively  attempted  by  patients,  who  press  the  foot  of 
the  well  limb  on  the  dorsum  of  the  foot  of  the  affected  side,  in  the 
endeavor  to  force  the  femur  away  from  the  acetabulum. 

The  influence  of  a  distracting  force  has  been  denied  by  some 
writers,  who  claim  that  it  is  impossible  to  draw  the  femur  away 
from  the  acetabulum,  to  which  the  head  of  the  femur  is  closely 
held  '  by  the  cotyloid  ligament. 

In  a  healthy  hip-joint,  if  all  muscles  are  dissected  away,  it  will  be 
found  difficult,  if  not  impossible,  to  pull  the  femur  from  the  acetab- 
ulum, if  the  pull  is  exerted  in  the  line  of  the  trunk;  if,  however, 
the  limb  is  abducted,  and  a  pull  exerted  in  a  direction  not  counter 
to  the  strength  of  the  ligament,  actual  distraction  takes  place. 

In  a  foetus,  or  young  child,  distraction  is  easy  from  a  downward 
pull  in  almost  all  directions,  for  the  cotyloid  ligament  of  a  foetus  is 
not  well  developed.  In  hip  disease  the  cartilage  becomes  softened 
and  practically  absorbed,  and  therefore  cannot  offer  the  resistance 
to  traction  which  is  to  be  met  in  a  healthy  joint. 

If  a  traction  force  be  applied  with  the  limb  strongly  adducted, 
the  head  of  the  femur  is  brought  against  the  rim  of  the  acetabulum. 
This  is  not  the  case  if  the  limb  is  slightly  abducted,  or  if  the  acetab- 
ulum has  not  attained  its  normal  adult  development.  But  in 
well-marked  hip  disease  in  children,  with  softening  of  the  cotyloid 
ligament  and  imperfectly  developed  acetabulum,  distraction  is  as 
feasible  as  at  the  metacarpo-phalangeal  articulation  of  the  fore- 
finger, where  the  bones  of  the  joint  can  easily  be  separated  by 
traction,  if  only  the  force  applied  be  sufficient  to  do  this. 

It  has  been  said  that  if  traction  is  applied  to  the  hip-joint  it 
will  crowd  the  lower  surface  of  the  head  of  the  femur  against 
the  lower  edge  of  the  acetabulum.  In  fact  this  will  be  found 
to  be  more  a  theoretical  than  a  practical  objection,  for  in  chil- 
dren the  acetabulum  is  not  deep,  and  a  slight  amount  of  abduc- 
tion is  all  that  is  necessary  to  overcome  this  difficulty,  as  will  be 
seen  on  examination  of  a  cadaver.  To  meet  this  objection,  Dr. 
Phelps  has  employed  an  appliance  which  is  designed  to  press  the 
femur  to  the  side.'' 

The  effect  of  traction  can  be  readily  estimated  by  any  surgeon, 
if,  in  excision  of  the  hip,  before  dislocating  the  head  of  the  femur, 
the  finger  is  placed  on  the  head  of  the  femur  close  to  the  rim  of 
the  acetabulum.     If  an  assistant  pulls  upon  the  limb,  the  finger  can 

^  Lannelongue  :    "  Coxotuberculose. "  '^  N.  Y.  Med.  Record,  March  4th,  1889. 


////'   DISEASE.  309 

be  inserted  between  the  head  of  the  fcnuir  and  the  acetabulum.  If 
the  pull  is  discontinued,  the  pressure  upon  the  finger  will  be  found 
to  be  considerable.  This  pressure  does  not,  of  course,  indicate  the 
pressure  due  to  muscular  force,  which  is  obliterated  under  an  an- 
aesthetic. 

But  experiments  with  a  view  to  determining  the  question 
whether  separation  of  the  joint  surfaces  takes  place  made  upon  the 
cadaver  and  upon  patients  under  ether,  do  not  reproduce  the  clini- 
cal conditions,  because  muscular  spasm,  the  most  important  factor 
of  all,  is  left  out  of  account.  Consequently,  conclusions  should  be 
drawn  very  carefully  from  these  experiments  as  to  what  traction 
mechanically  accomplishes  in  acute  hip  disease.  Konig  and 
Paschen  found  slight  separation  when  experimenting  upon  the  ca- 
daver and  using  traction  of  eight  pounds  and  more,  but  Morosoff, 
on  the  other  hand,  was  unable  to  produce  separation  of  the  joint 
surfaces  in  some  experiments  that  he  made  with  less  than  sixty 
pounds.  Lannelongue,'  by  frozen  sections,  demonstrated  a  partial 
separation  of  the  joint  surfaces  in  a  case  of  well-marked  hip  disease 
with  an  extension  of  ten  pounds. 

An  attempt  was  made  to  estimate  roughly  the  force  of  the  thigh 
muscles  in  a  boy  ten  years  old.  With  the  anterior  thigh  muscles, 
including  the  psoas  andiliacus  muscles,  in  flexing  the  thigh,  he 
could  exert  twenty-four  pounds'  pressure,  as  registered  by  a  spring 
balance  ;  with  the  posterior  thigh  muscles,  including  the  glutei,  he 
could  exert  a  force  of  twelve  pounds — a  total  force  of  thirt}'-six 
pounds  exerted  voluntarily  by  all  the  thigh  muscles.  If  these 
muscles  were  all  set  in  tetanic  rigidity  to  pull  the  head  of  the  femur 
against  the  acetabulum,  they  would  work  at  better  advantage  than 
in  the  experiment,  and  it  does  not  seem  likely  that  they  would 
exert  much  less  than  thirty-six  pounds'  pressure.  To  antagonize 
this  we  have  a  traction  force  at  the  most  of  from  5  to  15  pounds 
exerted  upon  movable  skin.  Practically,  however,  it  will  be 
found  by  measurement  in  certain  cases  of  hip  disease  under 
treatment,  that  an  actual  lengthening  of  the  limb  can  be  made  to 
take  place  by  traction.  The  muscular  spasm  yields  in  the  same 
way  that  is  seen  in  fracture  of  the  thigh  or  in  a  gradual  manual  trac- 
tion of  the  limb.  The  sedative  effect  of  traction  upon  the  muscles 
around  the  hip-joint  can  be  studied  in  observing  its  effect  in  cases 
of  congenital  dislocation  in  children  of  fi\"e  and  six  years;  traction 
when  first  applied  exerts  apparently  little  or  no  influence  on  the 
position  of  the  head  of  the  femur.  After  constant  application  of 
a  comparatively  small  traction  force,  five  pounds,  it  will  be  found 
in  a  few  weeks  that  the  head  may  be  pulled  from  its  previous  posi- 
'  Lannelongue,  quoting  Koenig,  etc.,    "  Coxotuberculose, "  Paris,  1SS6. 


3ro 


ORTHOPEDIC  SURGERY. 


tion  quite  noticeably,  and  kept  with  but  little  force  in  its  lower  atti- 
tude. If  the  thigh  is  flexed,  but  little  force  resisting  traction  will  be 
encountered,  demo-nstrating  that  the  chief  force  to  be  antagonized 
is  that  of  the  psoas  and  iliacus  muscle.  When  traction,  therefore, 
is  to  be  applied  efificiently  the  thigh  should  be  slightly  flexed. 

Traction  Splints. — Traction  splints  exert  their  power  upon  the 
joint  by  virtue  of  pulling  down  the  leg  against  a  counter-point  of 
pressure  furnished  by  the  perineum.    A  number  of  appliances  have 


Fig.  296.— Traction  Splint  for  the  Left  Leg,  seen  from  the  Back, 
provided  with  two  Perineal  Bands  and  an  Abduction  Screw. 


Fig.  297.- — Traction  Splint 
Applied. 


been  devised  for  the  purpose  of  traction,  the  principle  of  these  is 
practically  the  same,  viz.,  perineal  resistance  with  a  pulling  force 
exerted  on  the  limb.  As  in  most  appliances,  however,  the  details 
of  the  application  of  these  principles  are  of  so  much  importance, 
that  the  efficacy  of  such  treatment  will  depend  much  on  the  de- 
tails. 

The  traction  splint  in  common  use  is  some  modification  of  the 
original  Davis  splint.  This  form  of  appliance  is  now  generally 
known  as  the   "  long  traction  splint,"  as  well  as  the  Taylor  splint 


////'    IIISI-.ASE. 


3'i 


and  the  Sayrc  lonf;  spHnt;  an.l  various  modificafons  of  l    arc  , den- 

?ificc  withlhc  names'  of  the  surgeons  who  have  dev.sed  the  alten. 

ons      A  traction  appliance  consists  of   an  outs.de  steel  upnf;h 

reaching  from  the  trochanter  to  below  the  foot-,   at  the  upper  end 


1 


^'   ,  ^        •      c  r.f  Annlied         FiG  2QQ.-Traction  Splint  with  one  Perineal  Strap. 

Fig  298. -Single  Banded  Traction  Splint  AppUea.         r  ig.  ^yy 

is  a  horizontal  rigid  pelvic  girdle  in  which  the  P^';-^'  ■=J«"'-^f 
by  one  or  two  perineal  straps;  to  the  bottom  of  the  =='«'  '^^^t- 
ta'ched  some  appliance  for  exercising  tract.on  upon  the  hmb  the 
latter  being  well  held  to  the  bottom  of  the  sphnt  by  means  of  ad- 
hesive  plaster  gaiters,  circular  straps,  or  bandages. 


312  ORTHOPEDIC  SURGERY. 

In  the  adjustment  of  traction  to  varying  lengths  of  leg,  the  splint 
is  easily  provided  for  in  several  ways,  usually  by  means  of  a  sliding 
rod  moving  within  a  tube,  the  amount  of  motion  being  controlled 
by  means  of  a  key  and  ratchet,  a  spring  securing  the  rod  when  in 
the  proper  position.  This  constitutes  the  well-known  Davis-Taylor 
extension  splint,  illustrated  in  the  accompanying  diagram,  where 
a  form  of  the  splint  is  figured  having  only  one  perineal  band.  Such 
a  splint  has  the  disadvantage  in  acute  cases  of  affording  much  less 
complete  fixation  to  the  diseased  joint  than  the  form  with  the 
pelvic  band  and  two  perineal  straps. 

The  traction  splint  consists  of  a  rod,  hollow  at  the  lower  part, 
with  teeth  cut  on  the  edge  into  which  a  rod  plays,  by  means  of  a 
key.  The  rod  can  be  moved  up  and  down,  and  it  is  caught  and 
held  in  place  by  means  of  a  spring,  and  sliding  catch.  The  lower 
end  is  furnished  with  a  broadened  piece,  bent  so  as  to  pass  under  the 
foot,  and  a  strap  is  attached  to  it  which  can  be  buckled  into  buckles 
secured  to  the  adhesive  plaster  on  the  patient's  leg.  To  the  upper 
end  is  secured  an  arm,  which  passes  in  front  of  the  thigh,  and  to 
which  a  perineal  strap,  passing  under  the  perineum,  can  be  buckled. 
A  cheaper  arrangement  for  traction  can  be  furnished  by  means  of  a 
small  windlass  turned  by  a  key  with  a  ratchet  attached  to  the  foot 
piece  of  the  splint.  Upon  this  windlass  are  two  pins  to  which  the 
traction  straps  are  attached.  By  turning  the  key  traction  to  any 
degree  may  be  exerted. 

In  cases  where  is  a  sinus  or  abscess  over  the  outer  aspect  of  the 
thigh,  the  form  of  splint  shown  in  the  diagram  is  often  of  much  use. 
The  upright  is  divided  at  the  top  so  that  the  outer  surface  of 
the  thigh  is  not  pressed  upon  and  is  accessible  to  dressings  without 
the  removal  of  the  splint. 

Perineal  bands  may  be  made  of  webbing  covered  with  canton 
flannel  or  chamois  skin  or  silk;  pads  made  of  ground  cork  and 
covered  tightly  with  chamois  are  as  little  likely  as  any  to  chafe 
the  perineum.  Leather  sewed  smoothly  around  a  leather  strap  is 
the  cleanest  perineal  band  of  all;  but  in  the  hands  of  careless  per- 
sons it  becomes  hard  with  the  constant  wetting  from  urine  and  is 
liable  to  chafe.  If  hard  leather  is  used  it  should  be  constantly 
covered  with  vaseline  to  protect  it  from  urine. 

A  very  useful  perineal  band  devised  by  Dr.  E.  G.  Brackett,  of 
Boston,  is  shown  in  the  figure.  It  is  especially  comfortable  in  adult 
cases  and  in  the  larger  children,  and  offers  a  distinct  advantage  in 
this  way  to  any  perineal  band  that  the  writers  have  ever  used. 
The  posterior  bar  is  connected  by  a  strap  (E)  at  its  centre  to  the 
posterior  arm  of  the  brace,  thus  allowing  either  end  a  certain 
amount  of  vertical  oscillation.     The  three  buckles  are  fastened  to 


////'  nrsi'iASE. 


3^3 


a  similar  bar  (F),  which  has  two  straps  to  connect  it  with  the  an- 
terior arm,  Httle  or  no  motion  beinf(  allowed.  Between  these  straps 
and  the  perineum  is  a  piece  of  leather  (G),  its  size  re^ulatin^  that 
of  the  pad,  which  is  fastened  to  the  bar  behind.  This  serves  to 
transmit  the  pressure  of  the  straps,  and  also  to  keep  them  in  posi- 
tion, which  is  accomplished  by  button-hole  slits,  through  which  the 
straps  pass.  The  position  of  the  straps  is  as  follows:  The  outer 
one  (A)  passes  along  the  outer  border,  and  is  secured  to  the  outer 
buckle  (H).  It  should  pass  beneath  the  tuberosity  of  the  ischium. 
The  second,  or  middle  one  posteriorly  (B),  crosses  obliquely  inward 
to  the  inner  buckle,  and  by  this   more  nearly  corresponds  to  the 


Fig.  300. — Windlass  and  Ratchet       Fig.  301. — Traction  Splint  Modified 
for  Producing  Traction.  for  Application  over  Dressings. 


Fig.  302. — Brackett's  Perineal 
Band. 


direction  of  the  ramus  to  which  it  gives  its  support.  The  third,  or 
inner  (C),  crosses  the  one  just  described,  and  is  secured  to  the  mid- 
dle buckle,  and  gives  its  special  support  in  the  space  formed  by  the 
divergence  of  the  first  and  second.  By  this  crossing,  the  inner 
edge  of  the  pad  is  made  concave,  giving  better  adaptation  to  the 
parts.  By  this  arrangement  with  buckles,  the  surface  can  be  made 
to  fit  closely  all  the  parts  serving  for  support.  Felting  one  eighth 
of  an  inch  in  thickness  may  be  used  to  cover  the  leather.  ]\Iore 
than  this  should  not  be  used,  as  it  interferes  with  the  principle  of 
the  pad. 

The  care  of  the  perineum  is  one  of  the  important  practical  points 
in  the  treatment  of  hip  disease  when  a  traction  splint  is  used.  The 
form   of  perineal  band   chosen  will  depend  largely  upon  the  sur- 


314 


ORTHOPEDIC  SURGERY. 


geon's  personal  preference,  and  often  the  choice  has  to  be  made  by 
experimenting  with  different  kinds.  The  perineum  should  be  kept 
powdered,  and  it  should  be  bathed  in  alcohol  daily.  When  an  ex- 
coriation appears  the  perineal  band  should  be  covered  with  linen 
which  is  well-spread  with  vaseline  and  changed  often.  If  the  chafed 
spot  becomes  worse,  the  perineal  band  on  that  side  should  be 
removed  and  the  other  band  (if  an  appliance  with  two  perineal 
straps  is  used)  intrusted  with  the  whole  weight,  or  the  child  should 
be  put  to  bed,  the  splint  removed,  traction  by  means  of  a  weight 
and  pulley  in  bed  being  used  for  a  short  time  until  the  perineum 

is  healed.  Ordinarily,  with  pro- 
per care  and  cleanliness,  the  peri- 
neum is  able  to  bear  all  the  pres- 
sure needed. 

Traction  splints  were  intended 
for  use  for  patients  who  are  not 
confined  to  bed,  but  it  will  be 
found  that  traction  splints  can  be 
made  to  render  ef^cient  service 
to  patients  even  when  it  is  desira- 
ble to  postpone  ambulatory  treat- 
ment and  confine  the  patient  to 
bed.  The  traction  furnished  by 
traction  splints  will  be  found  more 
thorough  than  that  furnished  by 
the  weight  and  pulley  methods, 
although  the  latter  method  is 
much  simpler. 

Traction  Straps. — The  methods 
for  securing  a  hold  upon  the  limb, 
traction  straps,  as  they  are  termed, 
are  the  same  which  are  needed 
for  the  traction  by  weight  and  pulley.  The  readiest  way  to  obtain 
the  hold  upon  the  limb  for  an  extending  force,  is  by  means  of 
adhesive  plaster  applied  as  is  indicated  in  the  accompanying 
diagram.  It  should  be  applied  firmly  to  the  thigh  above  the 
knee,  so  as  to  secure  an  efficient  pull  upon  the  condyles  of  the 
femur.  If  applied  to  the  leg  alone,  traction  falls  upon  the  knee, 
and  may  cause  relaxation  of  the  ligaments  of  that  joint.  Effici- 
ent plaster  should  be  used,  of  a  kind  that  will  adhere  readily 
without  being  heated.  The  surgeon's  adhesive  plaster  furnished 
by  Seabury  &  Johnson  and  Grosvenor  &  Richards,  answers  the 
purpose  if  fresh.  The  plasters  should  be  changed  every  three  or 
four  weeks,  or  oftener  if  they  cause  irritation.     They  can  readily 


Fig.  303  — Adhesive  Plaster  for  Traction. 


////'    DISEASE.  315 

be  removed,  if  the  skin  ;in(l  [)l;istc.rs  be  tliorou^dily  moistened 
with  benzin.  If  any  j)ortion  of  the  limb  is  chafed  by  the  jjlasler, 
it  may  be  protected  by  means  of  a  cloth  placed  over  the  part,  and 
the  plaster  be  applied  over  tlie  ch)tl)  and  the  whole  limb;  or  if  tiie 
chafing  is  extensive,  the  whole  limb  can  be  covered  with  vaseline 
and  protected  by  a  smooth  bandage,  and  the  plaster  put  on  over 
the  bandaged  limb.  This  will  recjuire  frequent  renewal,  but  will 
answer  temporarily.  It  is  usually  the  practice  to  apply  a  bandage 
over  the  plaster,  but  this  impedes  the  circulation,  and  increases  the 
danger  of  eczema  or  chafing.  If  a  bandage  is  applied  over  the 
plaster,  and  worn  for  a  few  hours  after  it  is  first  put  on,  sufficient 
adhesion  of  the  plaster  will  be  secured  if  proper  plaster  is  used. 
In  certain  cases  an  obstinate  eczema  is  occasioned  by  the  adhesive 
plaster,  and  it  is  necessary  to  have  recourse  to  some  other  means 
of  extension.  Substitutes  for  plaster  can  be  made  by  the  use  of 
gaiters  applied  to  the  ankle,  or  straps  above  the  knee.  These, 
however,  will  slip  if  more  than  a  slight  traction  force  be  applied 
and  are  not  as  a  rule  satisfactory.  Another  form  of  traction  strap 
can  be  made  in  the  following  way:  cloth  or  thin  leather  is  cut  to 
fit  the  thigh  and  leg  accurately;  webbing  straps  and  buckles  or 
lacings  are  attached  which  when  tightened  give  a  hold  upon  the 
thigh  above  the  knee.  If  straps  are  sewn  to  this  leather  or  cloth 
legging,  they  can  be  made  to  furnish  efficient  traction ;  but  they 
are  likely  to  slip,  and  in  general  are  inferior  to  the  simple  adhesive 
plaster  as  a  means  of  traction. 

A  most  excellent  means  of  traction  can  be  furnished  by  what  is 
called  a  stocking  extension.  This  is  made  by  applying  to  the  limb 
a  long  tight-fitting  stocking,  which  should  reach  above  the  knee, 
having  tapes  sewed  at  both  sides,  which  should  be  longer  than  the 
child's  limb,  and  reach  a  considerable  distance  beyond  the  upper 
part  of  the  stocking;  a  bandage  should  then  be  applied  to  the 
leg  over  the  stocking,  and  the  tapes  reflected  down  the  leg  outside 
the  bandage,  and  a  second  bandage  applied  over  the  tapes,  which 
should  be  long  enough  to  extend  down  beyond  the  foot.  If  the 
tapes  are  fastened  to  the  traction  bar  a  pull  upon  the  leg  nearly  as 
efficient  as  that  afforded  by  adhesive  plaster  can  be  furnished. 

Ti-action  by  Weight  and  Pulley. — A  very  common  method  of  ap- 
plying traction  is  by  means  of  a  weight  applied  at  one  end  of  a 
cord,  which  passes  over  a  pulley  in  the  foot-board  of  the  bed ;  the 
other  end  of  the  cord  being  attached  to  the  traction  straps  on  the 
leg.  The  counter-extending  force  is  the  weight  of  the  body,  the 
foot  of  the  bed  being  raised  five  or  six  inches. 

This  method  necessaril}^  confines  the  patient  to  the  bed,  and 
unless  some  means  of  fixation  of  the  patient  is  employed,  it  is  nee- 


3l6  ORTHOPEDIC  SURGERY. 

essarily  an  unreliable  method,  as  a  slight  change  in  the  patient's 
attitude  may  shift  the  line  of  traction,  so  that  it  falls  in  a  way  to 
be  useless  or  even  injurious. 

If  the  patient  be  allowed  to  roll  about  in  bed,  or  sit  up,  or  hold 
the  limb  flexed  at  the  knee,  it  is  manifest  that  no  proper  traction 
force  is  being  used.  The  patient,  if  restless,  should  be  secured  by 
the  use  of  shoulder  straps  fastened  to  the  bed,  and  by  the  use  of 
sand-bags ;  or  better  still,  may  be  restrained  by  means  of  the  bed 
frame  to  be  described. 

The  ill  effect  of  a  pulling  force  not  in  the  line  of  the  deformity, 
in  acute  stages  of  hip  disease,  is  evident ;  the  psoas  and  iliacus 
muscles  being  contracted  by  the  spasm  incident  to  the  disease,  the 
thigh  is  flexed.  If  an  attempt  is  made  to  force  the  limb  down,  and 
a  pull  be  made  in  the  line  of  the  axis  of  the  body,  the  head  of  the 
femur  is  crowded  upward  to  the  anterior  edge  of  the  acetabulum, 
by  the  force  applied  at  the  end  of  the  lever,  viz.,  the  femur,  the 
attachment  of  the  psoas  and  iliacus  muscles  (holding  the  limb 
flexed),  furnishing  the  fulcrum.  In  milder  stages  of  the  disease  this 
is  not  as  important  as  in  the  acuter  stages,  but  it  is  a  mechanical 
error  in  any  stage  to  attempt  traction  except  in  the  line  of  the 
deformity.  This  error  is  often  the  occasion  of  increasing  the  pain 
and  sensitiveness  in  cases  of  hip  disease. 

The  advantage  of  traction  in  hip-joint  affections  has  been  suffi- 
ciently demonstrated  by  clinical  evidence,  but  it  is  frequently 
improperly  applied  and  affords  little  assistance.  The  following 
mistakes  are  not  uncommon:  i.  The  use  of  a  weight  too  small  to 
antagonize  to  any  extent  the  muscular  spasm  at  the  hip.  2,  The 
neglect  of  a  counter-extending  force,  or  the  use  of  an  imperfect 
one.  3.  Imperfect  hold  upon  the  leg  and  thigh.  4.  Improper  fix- 
ation of  the  patient's  trunk  and  limb,  allowing  motion  so  that  the 
traction  will  fall  upon  the  knee  and  not  upon  the  hip-joint.  5.  The 
use  of  the  pulling  force  in  such  a  direction  that  the  force  is  not 
exerted  in  the  line  of  deformity.  The  amount  of  weight  to  be  used 
varies  according  to  the  case;  the  patient's  sensation  maybe  trusted 
in  a  measure.  In  cases  of  severe  spasm,  as  much  as  twenty  pounds 
will  be  found  to  be  well  borne,  while  in  light  cases  and  in  small 
children  four  or  five  pounds  will  ordinarily  be  sufficient. 

If  precautions  are  taken  to  guard  against  these  errors,  traction 
will  be  found  of  great  value  in  the  treatment  of  hip  disease,  as  a 
means  of  diminishing  pain,  as  an  aid  in  fixation  of  the  hip,  and  for 
the  prevention  and  often  correction  of  deformity  of  the  hip. 

Fixation  Combined  zvith  Traction. — The  ordinary  means  of  fixa- 
tion, plaster  of  Paris,  Thomas  splint,  or  gouttiere  de  Bonnet,  as  has 
been   already  pointed   out,   do   not   prevent   entirely  the  muscular 


////'    DJSI'lASh:.  317 

Spasm  of  the  large  muscles  about  the  hip  which  crowds  the  femur 
into  the  acetabulum,  increasing  the  amfjunt  of  inflammatory  de- 
struction of  bone  at  the  joint,  eventually  causing  subluxation. 
Traction  furnishes  the  readiest  method  of  counteracting  this. 

It  has  been  claimed  by  some  writers  that,  if  thorough  traction  is 
employed,  fixation,  beyond  what  is  furnished  by  the  traction  ap- 
pliance, is  unnecessary,  although  practically  many  cases  may  be 
successfully  treated  without  complete  fixation,  yet  it  cannot  be 
assumed  as  a  surgical  aphorism  that  where  fixation  is  indicated,  it 
can  be  furnished  by  a  traction  force.  Some  experiments  have 
been  made '  with  a  view  to  determining  this  and  also  the  relative 
fixing  power  of  traction  splints  of  different  patterns. 

The  problem  presented  was  to  register  the  motion  between  the 
femur  and  the  pelvis,  if  any  such  motion  took  place,  when  the 
patient  walked  wearing  a  long  traction  splint,  and  for  this  purpose 
the  shaft  of  the  splint  was  extended  upward  two  or  three  inches  by 
an  adjustable  appliance  which  terminated  in  a  clamp  carrying'  a 
pencil  at  right  angles  to  the  skin.  It  was  evident  that  if  the  leg 
and  the  pelvis  moved  as  one,  if  there  was  no  motion  at  the  hip- 
joint,  the  pencil  would  record  on  the  skin  by  a  dot  only.  If,  how- 
ever, motion  took  place  between  the  leg  and  the  pelvis  in  the 
slightest  degree,  that  motion  would  be  registered  as  a  line  on  the 
skin,  indicating  the  arc  of  motion  at  the  hip-joint  that  the  leg  had 
described  in  walking. 

A  Taylor  hip-splint  of  the  ordinary  pattern  with  one  perineal 
strap  was  used  in  these  experiments.  In  two  experiments  the 
pencil  recorded  only  a  dot  when  a  boy  with  an  ankylosed  hip-joint 
walked  about  freely  and  sat  down  and  got  up  again,  showing  that 
when  there  was  no  motion  at  the  hip-joint  the  register  on  the  skin 
gave  no  arc. 

A  splint  fitted  with  the  register  was  then  applied  to  a  boy,  ten 
years  old,  whose  hip-joints  were  perfectly  normal,,  and  the  traction 
exerted  \yas  measured  by  two  spring  balances  inserted  in  the 
plaster  extension,  one  on  each  side.  A  traction  of  three  pounds 
and  a  half  was  then  exerted  by  means  of  the  ratchet  extension, 
and  the  boy  was  made  to  walk  freely  about.  It  was  found,  in  three 
experiments  made  under  these  conditions,  that  the  register  on  the 
skin  showed  that  the  hip-joint  had  moved  through  an  arc  of  35''  in 
the  simple  act  of  walking.  In  sitting  down  and  getting  up  again, 
about  the  same  amount  of  motion  was  caused,  the  traction  was 
then-  increased  up  to  eight  pounds,  when  it  became  almost  unbear- 
able, and  the  boy  could  only  be  induced  to  endure  it  for  a  ver\-  few 
minutes.  When  walking  was  attempted  with  this  amount  of  trac- 
■^  R.  W.  Lovett:  N.  Y.  Med.  Journ.,  Feb.  Sth,  iSSg. 


,i8 


ORTHOPEDIC  SURGERY. 


tion  (which  was  much  more  than  any  patient  could  endure  contin- 
uously), the  hip-joint  described  an  arc  of  15°.  One  may  conclude 
from  this  that  a  long  traction  splint  with  one  perineal  band  fur- 
nishes very  incomplete  fixation  to  a  healthy  hip-joint  with  any  en- 
durable degree  of  traction,  and  consequently  to  a  diseased  joint  it 
must  furnish  equally  poor  fixation. 

An  experiment  upon  the  same  boy  was  then  made  with  the  orig- 
inal form  of  Taylor  splint  as  now  used  at  the  New  York  Ortho- 
oedic  Hospital  and  Dispensary,  -^ 
which  has  a  rigid  waist-band  en- 
circling the  pelvis  and  two  perineal 
straps  instead  of  one;  and  when 
walking  was  attempted  with  that, 
very  much  better  fixation  was  ob- 
tained, although  it  still  lacked  a 
very  little  of  being  complete. 


G.  r  I  EM  ANN  &  CO. 
Fig.  304. — Short  Traction  Splint. 


Fig.  305. — Splint  for  Hip  Disease  .combining 
Fixation  and  Traction. 


So  far,  then,  as  these  experiments  go,  the  practical  points  shown 
are :  That  traction  in  itself  furnishes  very  incomplete  fixation  and 
cannot  be  regarded  as  in  itself  a  means  of  _;?a'/;z^  a  diseased  hip- 
joint  in  the  treatment  of  hip  disease;  and  that  a  long  traction  splint 
with  a  rigid  pelvic  band  and  two  perineal  straps  furnishes  much 
more  complete  fixation  to  the  joint  than  the  newer  form  of  the 
splint  with  only  one  perineal  strap. 

A  short  traction  splint  has  been  somewhat  used,  exerting  its 
traction  by  plaster  extension  upon  the  thigh  with  counter-traction 
by  means  of  a  perineal  strap.     It  was  originally  thought  that  this 


jjir  nish.Asi': 


319 


appliance  would  be  sufficient  to  meet  the  indications  in  the  h^diter 
cases,  the  patient  being  allowed  motion  at  the  hip-joint,  walking  by 
means  of  crutches;  but  it  has  proved  unsatisfactory  and  therefore 
cannot  be  recommended. 

A  splint  has  been  devised  which  provides  for  fixation  and  trac- 


FiG.  306. — Fixation  Frame. 


tion  while  the  patient  goes  about  (Fig.  305).  It  is  a  combination  of 
the  Thomas  splint  with  the  American  long  traction  splint,  and  its 
usefulness  is  found  chiefly  in  the  treatment  of  acuter  cases.     The 


Fig.  307. — Bed  Frame,  with  Traction  Apparatus  added. 


same  object  may  be  attained  by  applying  a  stiff  leather  or  silicate 
corset  to  the  patient's  trunk  and  to  this  attaching  a  traction  splint. 
In  the  most  acute  cases  confinement  in  a  recumbent  position  is 


Fig.  308. — Fixation  Frame,  with  Patient  in  Position. 


necessary  for  a  time.  Fixation  and  traction  can  be  furnished  by 
means  of  a  bed  frame  already  described  as  useful  in  caries  of  the 
spine,  and  adding  to  it  traction  by  means  of  a  traction  splint. 

The  patient  can  be  carried  about  upon  this  frame  as  readih'  as 


320 


ORTHOPEDIC  SURGERY. 


upon  a  gouttiere  de  Bonnet,  and  the  appliance  is  much  cheaper, 
more  readily  made  and  adjusted,  and  more  comfortable.  In  cases 
without  deformity  a  tractio'n  attachment  can  be  furnished  to  the 
end  of  the  frame,  and  this  can  be  used  instead  of  employing  a  trac- 
tion splint.  But  in  cases  where  recumbency  is  needed  but  a  short 
time,  the  ordinary  frame  with  the  traction  splint  will  be  found  to 
be  satisfactory.  When  the  patient  is  allowed  to  go  about,  he 
should  at  first  be  furnished  with  crutches;  the  shoe  on  the  well 
foot  should  be  raised  to  enable  the  affected  limb  to  swing  freely 
and  the  patient  allowed  to  go  about.  As  improvement  progresses, 
the  crutches  can  be  laid  aside,  and  the  patient  may  be  allowed  to 
walk  upon  the  end  of  the  traction  splint,  which  is  longer  than  the 
limb  and  furnished  with  a  foot-piece  protected  by  sole  leather. 

In  locomotion  in  this  way  a  certain  amount  of  traction  is  lost 
when  the  full  weight  of  the  body  falls  on  the  splint,  if  the  splint  is 
not  sufficiently  strong,  or  there  is  yielding  at  the  perineal  straps 
or  in  the  soft  parts  of  the  perineum.  This  can  be  in  a  measure 
obviated  by  the  use  of  a  strong  splint  or  by  furnishing  a  spring  in 
the  shaft  of  the  splint.  Practically  but  little  trouble  follows  in  a 
rigid  splint,  as  the  weight  of  the  limb  acts  as  a  traction  force  and  is 
efficient  when  the  patient  is  upright  and  throws  weight  upon  the 
splint. 

The  amount  of  traction  to  be  exerted  is  a  matter  which  must  be 
decided  by  the  surgeon's  preference.  Extreme  traction  cannot  be 
borne  nor  does  it  seem  to  be  necessary.  As  much  traction  should 
be  applied  as  can  be  comfortably  borne  by  patients.  In  the  acuter 
stages  the  patients  will  prefer  to  have  the  traction  straps  as  tight 
as  possible.  As  the  condition  of  the  joint  improves,  less  traction  is 
needed. 

Protection. — Certain  methods  of  treatment  aim  at  protecting  the 
joint  by  preventing  injurious  jar  from  being  inflicted  upon  the 
affected  joint.  The  simplest  way  to  protect  a  joint  is  with  the  use 
of  crutches,  the  sound  limb  being  raised  by  means  of  a  patten  on 
the  shoe  of  the  sound  limb,  enabling  the  affected  limb  to  swing 
free  of  the  floor.  The  weight  of  the  limb  exerts  a  certain  amount 
of  traction  force,  and  it  was  at  first  supposed  that  hip  disease  could 
be  treated  this  way  alone;'  although  this  supposition  has  not  been 
justified  by  facts,  and  it  has  been  found  that  although  distortion  of 
the  limb  and  subluxation  will  not  be  prevented  by  this  method, 
yet  excellent  protection  can  often  be  secured. 

The  ordinary  "  traction  "  splint,  as  described,  is,  in  reality,  a  pro- 
tecting as  well  as  a  traction  splint,  as  it  is  longer  than  the  limb  and 
passes  under  the  foot,  enabling  the  weight  to  be  borne  upon  the 
^  Hutchison  :   American  Journal  of  Medical  Sciences,  January,  1877. 


////'  nisi'.ASi'.. 


321 


splint  instead  of  the  patient's  foot.  I'rotectifjn  witlimit  traction 
can  be  furnished  by  omittin<.j  the  sliding  rod,  and  continuinp,^  the 
upright  rod  below  the  foot,  and  expanding  it  at  the  bottom  as  in 
the  extension  splint,  or  by  inserting  it  into  a  socket  in  the  boot. 
The  rod  should  be  long  enough  and  the  boot  so  arranged  that  the 
patient's  heel  should  not  touch  the  sole  of  the  boot,  though  the 
ball  of  the  foot  may  do  so.     The  greatest  jar  in  locomotion  comes 


Fig.  309. — Protection  Splint 
Applied. 


Fig.  310.— Protection  Splint  for  Con-      Fig.  311. — Protection  Splint  Ap- 
valescent  Hip  Disease.     (Left  leg.)        plied  with  Hinge  at  Knee-joint. 


as  the  heel  strikes  the  ground  at  the  commencement  of  the  step. 
If  this  jar  is  broken  by  the  splint,  the  remaining  jar  to  the  hip  in 
the  step  will  be  diminished  at  the  ankle  and  knee,  and  the  hip  suflfi- 
ciently  protected,  except  during  the  more  acute  stages  of  the  disease. 
The  ordinary  protection  splint  should  be  like  the  long  traction 
splint,  an  outside  steel  upright  with  two  horizontal  arms  at  a  level 
with  the  trochanter  carrying  a  perineal  band.  It  should  be  slotted 
below  into  a  steel  sole  plate  screwed  to  the  bottom  of  the  sole,  and 


322  ORTHOPEDIC  SURGERY. 

when  the  splint  is  in  place  and  the  perineal  band  buckled,  the 
patient's  heel  should  not  touch  the  heel  of  the  shoe,  but  hang  an 
inch  or  so  above  it, 

A  protection  splint  can  be  made  hinged  at  the  knee,  and,  if  prop- 
erly adjusted,  pktients  can  walk  about  readily  with  but  slight  dis- 
comfort. In  this  way  reliable  protection  is  secured  during  the  long 
period  of  convalescence  necessary  for  the  thorough  ossification  of 
the  affected  epiphysis.'  If  proper  protection  is  neglected  and  not 
continued  long  enough,  the  jar  of  locomotion — the  whole  weight 
being  thrown  upon  the  epiphysis  previously  carious — is  sufificient 
to  prolong  the  stage  of  irritability,  to  prevent  complete  cicatriza- 
tion and  ossification  of  the  inflamed  bone  tissue,  to  promote  con- 
traction of  the  limb  and  distortion,  and  in  many  instances  to  give 
rise  to  relapses  or  to  induce  contraction  and  distortion. 

Such  an  appliance,  Avhich  is  not  a  great  disfigurement,  and  will 
not  interfere  with  locomotion,  but  will  allow  walking,  and  the  free 
use  of  the  arms,  and  which  can  be  worn  without  discomfort  for  years 
if  necessary,  is  of  great  use  in  the  treatment  of  convalescent  hip  dis- 
ease. It  not  only  tends  to  prevent  relapse,  but  it  prevents  deform- 
ity. It  is,  of  course,  only  indicated  in  the  convalescent  stage,  and 
would  be  poor  treatment  in  an  acute  stage.  Simple  protection 
without  traction  is  not  to  be  relied  upon  if  muscular  spasm  is 
present,  as  this  can  be  determined  by  palpation  of  the  muscles  of 
the  hip.  If  muscular  spasm  is  present,  protection  and  traction 
should  both  be  employed. 
.  It  is  not  necessary  in  young  childen  that  the  splint  be  jointed  at 
the  knee  in  a  protection  splint.  The  additional  expense  which  this 
entails  can  be  avoided  by  changing  the  bottom  piece  of  the  ordi- 
nary traction  splint  for  a  piece  which  is  slotted  and  can  fit  into  a 
socket  fastened  to  the  shoe.  This  simple  arrangement  is  shown, 
in  the  figure  (Fig.  309).  In  an  appliance  of  this  sort  it  is  essen- 
tial that  the  perineal  strap  should  be  sufifiiciently  short  and  the 
splint  be  sufficiently  long  that  the  heel  of  the  foot  does  not  strike 
the  sole  of  the  shoe ;  so  long  as  this  is  so,  the  patient  is  in  a  mea- 
sure suspended  and  is  not  bearing  weight  upon  the  leg.  As  the 
patient's  condition  improves,  the  splint  can  be  shortened  and  jar 
gradually  be  allowed  to  come  upon  the  limb.  Protection  is  often 
needed  from  one  to  two  or  three  years  after  the  subsidence  of 
active  symptoms.  The  need  for  the  reapplication  of  protection  is 
indicated  by  a  reappearance  of  stiffness  or  increased  limping  on 
removal  of  the  splint.  The  older  the  patient  is  the  longer  protection 
will  be  needed. 

^  Mechanical  Treatment,  "  Hip-Joint  Disease,"  C.  F.  Taylor,  New  York;  and  E.  G. 
Brackett,  Boston  Medical  and  Surgical  Journal,  October  6th,  1887. 


nij>  nisi'iASE. 


323 


The  splint  advocated  by  \)x.  A.  B.  Judson  is  shown  in  the  fi^^ure. 
It  is  more  a  protective  than  a  traction  appliance  and  is  rather  a 
perineal  crutch  than  an  apparatus  for  exerting  much 
traction.  The  shaft  is  so  tapered  that  the  weight 
of  the  splint  is  centred  near  the  upper  part,  and  it 
is  thus  easier  to  manage  in  w.alking  than  the  ordinary 
splints.  It  is  finished  above  in  a  rigid  pelvic  arm 
which  is  covered  with  hard-rubber. 

Relapses. — Hip  disease  is  not  ended  when  the  acute 
symptoms  have  subsided;  a  process  which  requires 
so  long  a  time  for  its  development  requires  also  much 
time  for  its  disappearance.  Consequently  it  is  safer 
not  to  discontinue  traction  and  begin  simply  pro- 
tective treatment  as  soon  as  the  pain  and  acute  symp- 
toms are  gone,  and  it  is  safer  not  to  discontinue  pro- 
tective treatment  until  a  long  time  has  been  given 
to  the  joint  in  which  to  recover  itself. 

It  has  been  the  experience  of  the  writers  several 
times  to  see  a  relapse  started  up  by  a  change  to  pro- 
tective treatment  even  when  the  symptoms  of  hip 
disease  had  been  quiescent  for  months  and  there 
seemed  every  reason  to  believe  that  the  change  was 
a  safe  one. 

It  is  impossible  to  lay  down  rules  as  to  the  contin- 
uance of  treatment  further  than  to  say  that  traction 
and  partial  fixation  should  be  continued  until  all 
acute  symptoms  have  subsided  and  have  been  quies- 
cent for  months  and  only  partial  stiffness  of  the 
joint  remains  due  to  inflammatory  adhesions  and  not  to  muscular 
spasm,  and  that  protective  treatment  should  then  be  pursued  for 
two  or  three  years  at  least  and  discontinued  gradually. 


Fig.  312. — judbon's 
Perineal  Crutch. 


The  Treatment  of  Complications. 


Abscess. — In  certain  cases  of  hip  disease  the  epiphysitis  is  either 
so  diffuse  or  so  slight  that  the  cicatricial  process  follows  the  inflam- 
matory process  of  the  bone  without  undue  cell  proliferation;  but 
in  others  the  tuberculous  focus  is  neither  encapsulated  nor  ab- 
sorbed, but  is  sloughed  out  and  causes  an  irritation  and  an  abscess 
follows.     This  again  may  be  absorbed,  or  it  may  require  treatment. 

Simple  cold  abscesses  secondary  to  hip  disease  can  with  safetv 
be  left  to  themselves,  if  they  do  not  cause  constitutional  disturb- 
ance or  increase  rapidly.  It  is  desirable,  however,  that  pus  should 
be  prevented   from  burrowing  or  extending  in  a  great  varietv  of 


324  ORTHOPEDIC  SURGERY. 

directions.  This  can,  in  a  measure,  be  done  by  bandaging  the  limb, 
and  is  done  if  a  traction  splint  is  worn  efficiently ;  the  pus  being 
checked  from  extending  along  under  the  fasciae  by  the  resistance 
caused  by  the  perineal  strap  and  the  pressure  of  the  padded  plates. 
If  the  abscess  extends,  it  is  well  localized  in  a  large  majority,  of 
cases,  and  can  extend  only  outwardly. 

If  abscesses  are  well-localized  and  increasing  in  size,  and  they 
are  left  to  burst  spontaneously,  they  often  are  thoroughly  evac- 
uated, leaving  a  sinus  which,  after  discharging  for  some  time,  finally 
heals.  Often,  however,  the  abscess  is  not  completely  evacuated. 
Some  residue  remains,  and,  gravitating  along  the  lines  of  fasciae, 
it  gives  rise  to  the  development  of  another  abscess,  until  several 
collections  of  pus  may  be  developed  about  the  joint.  It  is  better 
in  such  cases  to  open  the  original  abscess  freely,  so  that  thorough 
drainage  is  furnished — large  incisions  being  better  than  small.  The 
pyogenic  membrane  should  be  dissected  off  or  curetted,  and  if  that 
is  done,  with  thorough  asepsis,  and  proper  dressings  applied,  it  is 
not  uncommon,  when  active  disease  of  the  bone  has  subsided,  for 
such  abscesses  to  heal  up  entirely  by  first  intention,  without  recur- 
rence or  sinus  formation.  To  gain  such  results  two  things  are  es- 
sential, viz.,  thorough  drainage  of  the  Avhole  abscess  and  perfect 
asepsis.  It  is,  of  course,  necessary  that  thorough  treatment  for  the 
ostitis  be  not  interrupted. 

Certain  surgeons,  however,  believe  in  non-interference  in  hip 
abscess,  unless  the  symptoms  are  so  acute  as  to  render  it  necessary, 
urging  the  danger  of  septic  or  tubercular  infection  in  opening  them, 
and  also  calling  attention  to  the  fact  that  these  abscesses  may  be 
absorbed.  The  danger  of  sepsis  should  not  be  present,  although 
there  is  a  certain  danger  of  tubercular  infection.  This  point  of 
view  is  very  ably  stated  by  Dr.  A.  B.  Judson  in  a  paper  recently 
read.'  He  says,  "  I  should  not  omit  to  give  my  reasons  for  failing 
to  see  the  importance  of  incision,  scraping,  and  antiseptic  closure 
of  the  abscesses  in  question.  Incision  is  a  tardy  and  fruitless  pro- 
cedure. The  most  painful  stage  in  the  history  of  the  abscess  is 
long  past.  It  was  present  when  the  pus  was  collecting  under  the 
periosteum  and  in  the  cells  of  bone.  If  we  could  interfere  early 
with  the  bistoury  and  knew  where  to  direct  its  point,  we  might 
relieve  the'  pain,  and  perhaps,  in  favorable  circumstances,  shorten 
the  case  and  save  bony  tissue  by  dividing  the  thickened  periosteum 
or  breaking  the  shell  of  compact  bone.  But  when  the  pus  is  in  the 
cellular  structures  or  the  cavity  of  the  joint,  I  do  not  see  that  the 
progress  of  the  case  can  be  materially  affected  by  interference.  If 
the  abscess  is  cold,  there  is  no  painful  tension  to  be  relieved.  If 
^  N.  Y.  Med.  Jour.,  March  2d,  1889. 


////'  DISEASE.  325 

it  is  phlegmonous,  tension  is  the  result  of  inflammatory  infiltration 
and  can  be  relieved  only  by  extensive  and  multi[jle  incisions.  If 
we  operate  in  either  case,  we  substitute  artificial  for  natural  closure, 
and  with  the  best  antisepsis  we  gain  nothing  by  operating  unless 
we  reach  and  scrape  out  the  purulent  depot  or  the  interior  of  the 
joint,  and  then  nothing  unless  we  remove  the  eroded  cartilage  and 
exfoliating  bone  and  excavate  the  focus,  and  then  nothing  in  many 
cases  unless  we  remove  large  quantities  of  bone  or  excise  the  joint. 
And  if  we  operate  in  the  manner  described  we  do  not  avoid  the 
necessity  of  bringing  to  bear  the  best  mechanical  treatment  and 
hygienic  control,  which,  if  they  are  supplied,  will  bring  about  a  re- 
covery, whether  we  operate  or  not,  by  the  slow  but  sure  process  of 
natural  repair,  with  the  better  result  the  less  we  interfere  with  the 
soft  parts,  as  a  general  rule." 

In  general,  however,  modern  surgical  opinion  inclines  to  advo- 
cate the  incision  and  antiseptic  evacuation  of  collections  of  pus  in 
connection  with  the  hip-joint  as  well  as  elsewhere  in  the  body. 
The  practical  fact  seems  to  be  that  in  many  cases  incision,  cleans- 
ing and  drainage  will  cause  the  speedy  closure  of  an  abscess  which 
might  otherwise  have  been  incompletely  evacuated  and  which 
would  have  discharged  for  months;  for  in  many  cases  the  temper- 
ature will  fall  and  the  general  condition  immediately  improve  after 
the  opening  of  the  abscess. 

When,  however,  an  abscess  has  developed  gradually,  gives  no 
discomfort,  and  is  not  increasing,  and  the  patient  is  free  from  ele- 
vation of  temperature,  it  can  be  left  undisturbed.  Absorption  may 
occur  even  after  fluctuation  has  become  distinct  and  the  abscess 
is  apparently  superficial.  Rapid  or  constant  increase  of  size  and 
fever  at  night  should  be  considered  indications  for  incision.  An 
acute  abscess  causing  pain  and  discomfort  should  be  opened  with- 
out delay. 

Pelvic  Abscess. — Habern  '  classifies  these  abscesses  as  follows: 

(i)  Those  which  are  dependent  upon  disease  or  perforation  of 
the  acetabulum. 

(2)  Those  from  the  rupture  of  the  capsule  in  purulent  coxitis  on 
the  inner  and  upper  insertion.  The  pus  passes  over  the  pubic 
bone  into  the  fossa  iliaca. 

(3)  That  form  which  results  from  an  extension  upward  of  an 
abscess  formed  between  and  beneath  the  adductors,  and  spreading 
along  the  ilio-psoas  muscle  into  the  pelvis, 

(4)  Para-articular  abscesses  without  communication  with  an  in- 
flamed joint. 

Habern  classifies  his  results  as  follows :    Of  those  not  operated 

"  Centralblatt  f.  Chir. ,  April  2d,  iSSi. 


326  ORTHOPEDIC  SURGERY. 

upon  in  three  years  19  per  cent  had  recovered;  15  per  cent  died; 
66  were  not  well.  In  four  years,  26  per  cent  had  recovered;  17 
died;  57  not  well.  In  five  years,  24  per  cent  had  recovered  ;  21  had 
died;  55  not  well.  Taking  all  the  cases  (those  operated  and  not 
operated),  at  the  end  of  five  years,  13  per  cent  were  well  without 
operation;  37  were  resected,  with  a  mortality  of  51  percent;  11 
per  cent  had  been  amputated,  with  a  mortality  of  60  per  cent ;  and 
29  per  cent  had  remained  not  well. 

Aspiration  of  abscesses  is  generally  an  exceedingly  unsatisfactory 
measure,  but  occasionally  (not  commonly)  an  abscess  will  be  ab- 
sorbed after  one  or  two  aspirations.  As  a  rule  it  refills  again  and 
again,  with  greater  or  less  rapidity,  until  the  method  is  abandoned. 
A  large  needle  must  be  used  in  these  aspirations  and  often  the  pus 
will  not  flow  through  that  on  account  of  the  flakes  contained  in  the 
pus  of  cold  abscesses.  Continued  aspiration  at  one  point  will  so 
weaken  that  part  of  the  abscess  that  a  spontaneous  opening  will 
probably  occur  there  and  incision  may  after  all  be  required. 

Injection,  after  aspiration,  of  the  abscess  cavity  with  iodoform 
and  glycerin  or  iodoform  and  ether,  is  sometimes  useful.  With 
the  latter  one  must  provide  a  vent  for  the  volatized  ether,  for  the 
heat  of  the  body  is  enough  to  cause  the  conversion  of  the  ether  to 
vapor  and  in  a  closed  cavity  the  distention  produced  may  be  pain- 
ful and  even  dangerous.  The  hyper-distention  of  the  cavity  with 
carbolic-acid  solution  is  unsafe  on  account  of  the  risk  of  fatal  poi- 
soning, which  is  not  unlikely  in  young  children.  The  writers  would 
record  as  a  warning  the  death  of  a  patient  with  a  cold  abscess  of 
hip  disease,  from  carbolic-acid  poisoning,  following  the  washing  out 
of  a  small  abscess  cavity  with  a  few  ounces  of  a  i-to-40  solution  of 
carbolic  acid.  As  a  rule,  if  it  seems  desirable  to  adopt  any  opera- 
tive measure  in  the  treatment  of  a  hip  abscess,  incision  is  the  safest 
and  most  satisfactory. 

Night  Cries. — A  troublesome  complication  in  the  early  stages  of 
hip  disease  is  often  the  nocturnal  cry.  These  usually  disappear 
after  thorough  fixation  with  traction.  In  some  instances,  however, 
the  cries  persist  for  weeks  or  months,  but  they  are  certain  to  dis- 
appear after  the  subsidence  of  the  acute  stages  of  the  affection. 
The  application  of  blisters  back  of  the  trochanter,  the  use  of  poul- 
tices, and  the  compression  of  the  thigh  muscles  by  a  tight  bandage, 
have  been  advised  as  a  means  of  diminishing  the  sensitiveness  of  the 
joint.  The  administration  of  salicylate  of  soda  in  large  doses '  is 
frequently  efificient  in  checking  night  cries  and  sensitiveness  of  the 
joint.  It  should  be  given  in  doses  of  the  same  size  which  would 
be  used  to  control  acute  articular  rheumatism,  and  it  will  rarely  fail 

'  R.  W.  Lovett  :  Boston  Medical  and  Surgical  Journal,  April,  i88g. 


jur  nish.ASi-:.  527 

to  give  at  least  temporary  relief.  Although  opiates,  chloral,  and 
bromide  of  potash  in  large  doses  will  often  give  relief,  the 
use  of  them  is  to  be  avoided  if  possible  in  liip  disease,  as  the 
pain  they  are  to  check  is  momentary,  and  the  effect  of  the  narcotic 
persists  and  is  injurious  upon  the  appetite  and  nervous  system. 

Stretching  the  sciatic  nerve,  trephining  the  head  of  the  femur, 
and  direct  incision  of  the  joint  have  been  advised  and  tried  with 
success  in  aggravated  cases  of  this  sort. 

The  most  efficient  means  for  correcting  night  cries  is  absolute 
fixation  of  the  joint  in  the  line  of  deformity  if  malposition  is  pres- 
ent. When  traction  is  used,  it  should  be  employed  with  the 
limb  elevated  so  as  to  avoid  stretching  the  psoas  and  iliacus  mus- 
cles ;  the  limb  should  be  well  supported  and  traction  made  in  the 
line  of  the  deformity  if  any  is  present.  Night  cries  will  often  sub- 
side quickly  and  not  reappear. 

Malpositio)is  of  tJie  Limb. — Distorted  attitudes  of  the  limb  are  in- 
cidental to  the  clinical  history  of  hip  disease,  and  the  correction  and 
prevention  of  them  form  an  essential  part  of  treatment.  In  the 
earlier  stages  of  the  disease  there  is  little  difficulty  in  correcting 
the  existing  deformities  due  to  abnormal  muscular  contractions  or 
malpositions  of  the  limb,  the  ordinary  treatment  of  hip  disease 
being  sufficient  to  correct  deformity.  If  traction  is  applied  in  the 
line  of  the  deformity,  it  will  be  found,  in  a  few  days,  in  the  early 
stages  of  the  disease,  that  the  limb  can  be  placed  in  a  more  nearly 
normal  position  until  it  eventually  becomes  straight. 

The  deformities  occurring  are  flexion,  abduction,  and  adduction. 
Flexion  can  be  corrected  by  thorough  traction  in  the  line  of  the 
deformity,  as  already  mentioned.  It  will  be  found  that  a  traction 
splint  is  more  efficient  for  this  purpose  that  the  simple  weight-and- 
pulley  traction ;  the  patient  should  be  fixed  in  bed,  a  traction  splint 
applied,  the  flexed  limb  raised  to  the  angle  of  deformity  so  that 
the  back  is  flat,  and  attaching,  if  necessary,  to  the  traction  splint 
the  weight  and  pulley  to  give  additional  fixation  to  the  limb.  It 
will  be  found  in  a  majority  of  cases  that  each  day  the  angle  of  de- 
formity is  less  and  the  limb  can  be  lowered.  Flexion  can  also  be 
corrected  by  means  of  the  Thomas  splint  bent  to  fit  the  flexed  limb 
and  gradually  straightened. 

Slight  cases  of  deformity  can  be  corrected  by  the  use  of  appli- 
ances such  as  traction  splints  which  allow  the  patient  to  go  about 
with  the  aid  of  crutches ;  but  in  the  severer  cases  rest  in  bed 
hastens  correction.  The  traction  splint  naturally  antagonizes  ad- 
duction of  the  limb  by  virtue  of  its  pulling  the  leg  against  a  coun- 
ter-point in  the  perineum  which  tends  to  abduct  the  leg  to  which 
the  splint  is  applied. 


328 


OR  THOPEDIC  S  URGER  Y. 


Deformities  in  the  early  stage  of  hip  disease  may  be  corrected  by 
anaesthetizing  the  patient  and  placing  the  limb  in  a  normal  posi- 
tion, holding  it  in  a  corrected  position  by  means  of  plaster  of 
Paris  splints.  There  is  but  slight  danger  following  careful  cor- 
rection in  this  way,  but  the  method  is  rough  and  inferior  to  the 
gradual  methods. 

Abduction  usually  corrects  itself  under  the  ordinary  treatment 
for  hip  disease,  or  is  changed  to  adduction  in  the  natural  course  of 
the  disease.  The  same  may  be  said  of  adduction,  but  this  latter 
distortion  is  often  more  persistent.  It  can  generally  be  corrected 
by  the  ordinary  weight-and-pulley  method,  with  fixation  in  bed. 
The  most  satisfactory  method  to  pursue  is  to  put  the  patient  to 
bed  with  a  weight  and  pulley  exerting  traction  upon  the  leg  in  the 
line  of  the  deformity  and  gradually  restoring  the  leg  to  a  more 


Fig.  313. — Fixation  Frame,  with  Inclined  Plane  Attached. 

normal  position,  as  can  be  done  with  surprising  facility  day  by  day. 
The  same  end  can  be  accomplished  by  confinement  to  bed  and  the 
application  of  a  traction  splint  to  the  leg  supported  in  the  line  of 
the  deformity  and  changed  daily  toward  a  normal  position,  which  will 
be  found  more  efficient,  the  traction  in  the  line  of  the  deformity 
serving  as  a  sedative  to  quiet  the  muscular  irritability  and  thus 
enable  the  limb  to  be  restored  to  a  more  correct  position.  Mr. 
Howard  Marsh  has  employed  an  excellent  method,  which  is  easily 
applied  in  cases  of  adduction,  using  the  ordinary  weight-and-pulley 
traction  on  each  limb,  that  applied  to  the  adducted  limb  pulling 
downward  toward  the  foot  of  the  bed  and  that  on  the  normal  limb 
pulling  upward  toward  the  head  of  the  bed. 

In  the  correction  of  adduction  a  most  efficient  appliance  is  one 
recommended  by  Dr.  H.  L.  Taylor,  of  New  York  (Fig.  314).'  It  is 
used  during  recumbency  and  is  particularly  suited  to  the  correction 

'  New  York  Medical  Journal,  November  igth,  1887. 


////'  j)/sjwisj':. 


329 


of  the  relapsed  and  difficult  cases  occurring  in  the  late  stages  of 
the  disease. 

In  later  st^iges  of  severe  deformity,  forcifjle  straightening  under 
an  anaesthetic  (with  or  without  division  of  the  adductor  tendons 
and  the  division  of  the  fascia  lata  by  open  incision),  or  osteoclasis, 
or  osteotomy  have  been  advised,'  and  are  of  use. 

In  the  older  cases  of  deformity,  where  there  is  probably  fibrous 
but  not  bony  ankylosis,  much  can  be  done  in  the  way  of  correction 
by  confinement  to  bed  and  traction  with  considerable  weights.  In 
this  way  the  writers  were  able  to  correct  an  ad- 
duction deformity  which  could  not  be  rectified 
under  ether  with  the  use  of  any  justifiable  amount 
of  force.  And  again  a  case  of  right-angled  flexion 
of  one  hip  was  corrected  in  a  young  girl,  who 
was  not  willing  to  have  an  operation,  by  con- 
tinued confinement  to  bed  and  traction;  the  well 
leg  being  flexed  (as  in  Thomas's  test  for  flexion) 
to  furnish  a  resistance  to  the  traction  force  and 
prevent  lordosis  of  the  lumbar 
spine. 

Forcible  Correction  of  Deformity. 
— Where  the  deformity  is  not  to  be 
corrected  by  mechanical  means  or  by 
simple  reposition  of  the  limb  under 
ether,  operative  measures  can  be  re- 
sorted to.     These  are : 

1.  Brisement    force    with    one    or 
more  sittings  followed  by  fixation. 

2.  Tenotomy,  myotomy,  and  fasci- 
otomy  as  a  prelude  to  brisement  force. 

3.  Osteoclasis. 

4.  Osteotomy. 
Forcible   maniial    correction    is    often    efifica- 

cious,  and  is  not  attended  by  as  much  risk  as  might  be  supposed 
in  the  cases  of  children  or  adolescents.  There  is  some  danger 
of  fracture  of  the  bone  in  resistant  cases  and  also  the  risk  of 
lighting  up  the  disease  by  the  force  to  the  joint.  This  might  easily 
happen  by  setting  free  an  encapsulated  focus  of  tuberculous  ma- 
terial which  had  ceased  to  be  active. 

Tenotomy  and  JMyotomy  Folloived  by  Forcible  Straightening. — 
The  skin,  as  Volkmann  has  shown,  is  not  of  much  importance  in 
maintaining  the  contraction  of  the  hip-joint,  but  the  fascia  lata  is 
troublesome  and  particularly  the  intermuscular  ligament  between 

'  Rosmanit:  Archiv  f.  klin.  Chir.,  1SS2,  Bd.  2S.  i. 


Fig.  314. — Taylor's  Adduction 
Splint. 


330 


ORTHOPEDIC  SURGERY. 


the  rectus  and  tensor  vaginse  femoris  muscles.  Froriep  has  shown 
that  in  the  contraction  of  the  hip  and  knee  the  muscles  are  not  as 
powerful  in  fixing  the  distortion  as  the  connective  tissue.  Wini- 
warter has-  recently  revived  and  Billroth  performed  the  open  in- 
cision of  the  soft  tissues  in  contractions'  of  this  sort.  A  V-shaped 
incision  is  made  from  Poupart's  ligament  to  the  front  of  the  thigh, 
the  size  depending  upon  the  amount  of  contracted  tissue.  After 
the  division  of  the  skin  and  fascia,  attempts  should  be  made  to 
straighten  the  limb,  which  sometimes  can  be  done  without  division 
of  the  muscles;  this,  however,  can  safely  be  done  even  down  to  the 
capsule  of  the  joint.  After  the  limb  has  been  straightened  it  should 
be  fixed  either  by  plaster  of  Paris  or  by  extension,  with   fixation 


Fig.  315. — Apparatus  for  Fixing  the  Pelvis  in  Osteoclasis  of  the  Hip. 


of  the  pelvis,  the  choice  depending  upon  the  experience  and  pre- 
ference of  the  surgeon. 

Osteoclasis. — -Where  there  is  osseous  ankylosis  or  very  firm  fibrous 
union  within  the  joint,  either  osteoclasis  or  osteotomy  are  to  be 
resorted  to.  Manual  osteoclasis  is  sometimes  done  in  attempts  at 
brisement  force,  but  it  is  rarely,  if  ever,  now  used  intentionally. 

Mechanical  osteoclasis  has  been  successfully  performed  by  Dr. 
C.  F.  Taylor,  of  New  York,  and  appliances  have  been  used  to  aid  in 
fixing  the  pelvis  as  a  help  to  manual  osteoclasis.  There  is,  how- 
ever, a  lack  of  precision  as  to  the  site  of  fracture,  and  osteotomy 
is  now  to  be  regarded  as  preferable. 

Osteotomy. — Osteotomy  is  by  far  the  most  preferable  of  the  ope- 
rative procedures  for  the  correction  of  deformities  of  the  hip  due 
to  bony  ankylosis.  Rhea  Barton'  performed  osteotomy  in  1826, 
for  the  correction  of  bony  ankylosis  of  the  hip  at  a  right  angle  and 
^  North  American  Med.  and  Surg.  Journ.,  1827,  iii.,  279. 


////'  n/S/CASE. 


331 


obtained  a  movable  joint.  He  was  followed  by  Rodger,  Clemot, 
Maisonneuve  and  a  succession  of  other  surgeons,  including  Dr. 
Sayre.  A  very  decided  advance  was  made  when  Adams  performed 
the  operation  through  a  very  small  external  wound,  using  a  keyhole 
saw  for  section  of  the  bone. 

The  methods  of  operating  have  varied  very  much  with  the  devel- 
opment of  the  operation.  The  earliest  operators  divided  the  bone 
above  the  great  trochanter  or  at  least  between  the  trochanter 
major  and  minor.  Adams'  operation  is  devised  for  section  of.  the 
neck  of  the  femur,  and  can  only  be  performed  where  the  neck  is 
present.  Barton,  Bar- 
well,  Maisonneuve,  and 
Sayre,  however,  have 
performed  the  operation 
lower  down,  but  all  above 
the  trochanter  minor, 
until  Gant '  devised  the 
operation  of  subtrochan- 
teric osteotomy,  by  which 
the  femur  is  divided  be- 
low the  trochanter  minor. 
The  anatomical  reasons 
which  he  gave  for  this 
step  were  that  the  resist- 
ance of  the  psoas  and 
iliacus  muscles  was  set 
free  and  that  a  return  of 
the  flexion  was  not  there- 
fore to  be  expected,  as 
when  the  bone  was  divid- 
ed above  the  attachment 
of  these  muscles.  He 
also  called  attention  to 
the  fact  that  in  operating  for  ankylosis,  after  hip  disease,  it  was 
desirable,  if  possible,  to  make  the  section  through  healthy  bone  and 
as  far  as  possible  from  the  original  seat  of  the  disease;  in  this 
way  diminishing  the  liability  of  rekindling  the  old  joint  inflam- 
mation. Stephen  Smith  has  performed  a  modification  of  this  oper- 
ation in  sawing  one  half  through  the  femur  at  different  levels,  one- 
half  an  inch  apart  and  then  breaking  the  bone  by  manual  force.  In 
doing  this  he  made  a  half  tenon  and  mortise,  the  object  of  which 
was  to  prevent  any  further  displacement  of  the  lower  fragment 
which  might  endanger  firm  union  at  the  point  of  section. - 


Fig.  317. 
Figs.  315  and  316. — Former  Apparatus  for  Fixation  after 
Forcible  Straightening. 


'  Lancet,  Dec,  1872,  p.  S81. 


Med.  Rec,  June  2d,  1SS3,  p.  589. 


332 


ORTHOPEDIC  SURGERY. 


Volkmann '  has  removed  a  wedge-shaped  piece  of  bone  from  the 
trochanter  major  in  order  to  correct  adduction  of  the  Hmb,  and 
later,  in  place  of  performing  simple  osteotomy,  he  substituted  an 
excision  of  the  joint  by  a  chisel  and  gouge,  first  performing  a  regu- 
lar linear  osteotomy  and  then  removing  the  head  and  neck  of  the 
bone  in  small  pieces.  He  reported  six  patients  operated  upon  in 
this  way  who  recovered,  with  the  establishment  of  a  new  articula- 
tion." 

To-day  Gant's  operation  takes  precedence  of  all  others  in  the 
correction  of  bony  ankylosis  with  deformity  after  hip  disease  and 
after  arthritis  deformans.  The  reasons  why  the  operation  is  to  be 
preferred  in  these  cases  is  thus  stated  by  Mr.  Gant:^ 
^'  When  in  consequence  of  continued  disease  of  the 
hip-joint  the  head  of  the  femur  has  disappeared,  leav- 
ing only  a  stunted  nodule  of  bone  representing  the 
neck  above  the  trochanter,  in  such  a  case  the  opera 
tion  of  section  in  the  femoral  neck  cannot  be  per-  jgl}'/ 
formed,  there  being  no  neck  to  divide. 
Even  when  supra-trochanteric  section 
is  practicable,  the  state  of  the  neck  may 


Fig.  318. — Diagram  of  Lines  for  Osteotomy  of  the  Hip. 
<a!,  Adams'  Operation;  b^  Intertrochanteric  Section;  c, 
Gant's  Operation. 


-Anchylosis  of  the  Hip  Joint 
at  a  Right  Angle. 


render  this  operation  abortive.  The  seat  of  the  operation  will  be  in 
an  almost  carious  portion  of  bone  which  is  unfit  to  yield  a  fibrous 
union."  This  is  not,  however,  the  case  when  ankylosis  has  resulted 
from  an  acute  traumatic  inflammation  of  the  hip ;  then  the  Adams 
operation  is  justifiable.  If  the  object  of  operation  were  to  obtain 
a  movable  joint,  it  would  be  desirable  to  make  the  section  as  near 
the  true  axis  of  motion  as  possible ;  but  a  movable  articulation  is 
seldom  if  ever  obtained,  and  it  is  not  worth  while  to  attempt  to  se- 
cure it  by  the  removal  of  a  wedge  of  bone,  or  anything  of  the  sort, 
A  straight  linear  osteotomy  answers  every  purpose  equally  well. 
Gant's  operation  should  then  be  chosen  for  the  correction  by  an- 


'  Cent.  f.  Chir.,  1874,  i. 

3  Brit.  Med.  Journal,  Oct.  i8th,  1879. 


2  Cent.  f.  Chir.,  1880,  v. 


Hir   DISEASE. 


333 


kylosis  after  hip  disease.  Smith's  more  complicated  section  of  the 
bone  offers  no  practical  advantage,  while  Volkmann's  combination 
of  osteotomy  and  excision  has  found  few  advocates,  on  account  of 
its  difficulty  and  tediousness. 

The  osteotome  is  a  chisel,  which  should  possess  a  temper  about 


Fig.  320.  Fig.  321. 

Flexion  and  Adduction  of  the  Right  Leg  corrected  by  Gant's  Operation. 


half  way  between  that  of  a  cold  chisel  and  a  carpenter's  cutting 
tool,  so  that  the  edge  of  it  will  not  be  turned  by  the  hardness  of 
the  bone.  The  cutting  edge  should  be  very  sharp  and  the  width 
of  the  blade  about  half  an  inch.  It  is  convenient  to  have  several 
osteotomes  of  the  same  width,  but  of  different  thicknesses,  so  that 


334 


ORTHOPEDIC  SURGERY. 


if  one  becomes  wedged  in  the  bone  it  can  be  withdrawn  and  a 
thinner  one  substituted.  The  blade  should  be  marked  with  a  line 
every  half  or  quarter  of  an  inch  from  the  cutting  edge  so  that  one 
can  tell  how  deeply  the  osteotome  has  penetrated.     A  fair-sized 


Fig.  322.— Case  of  Right  Angled  Flexion  of  the  Hrp  before  Operation.     i^Vance.) 

carpenter's  mallet  answers  better  than  any  of  the  lead  or  steel  ones 
found  in  the  instrument  shops. 

In  the  performance  of  the  operation  the  patient  lies  on  the  side 
with  a  sand  pillow  between  the  legs,  and  the  skin  is  scrubbed  and 
sterilized  as  carefully  as  in  any  operation.  An  incision  may  be 
made  exposing  the  femur,  or  the  chisel  may  be  driven  in  through 


////'    />/S/C/lS/C. 


335 


the  sound  skin  about  an  incli  or  an  incli  and  a  half  below  the  f:jreat 
trochanter,  accor(h"nir  to  whetlier  one  is  ojjerating  upon  an  adoles- 
cent or  an  adult.  The  chisel  sliould  at  first  be  held  with  the  blade 
in  the  long  axis  of  the  limb  and  turned  when  it   reaches  the  bone, 


Fig.  323. — Result  of  Gant's  Operation  in  a  Case  of  Right  Angled  Flexion  of  the  Hip.     (Vance.) 

until  its  edge  is  at  right  angles  to  the  axis  of  the  limb.  The  osteo- 
tome should  then  be  driven  into  the  bone  by  sharp  blows  with  the 
mallet,  turning  the  cutting  edge  first  forward  and  then  backward, 
so  as  to  cut  obliquely  through  the  whole  shaft.  If  the  osteotome 
becomes  wedged  it  should  be  loosened  by  lateral  motions  and  a 


336  ORTHOPEDIC  SURGERY. 

thinner  one  substituted  if  possible.  Any  attempt  at  prying  with 
the  osteotome  would  probably  result  in  breaking  the  blade.  When 
the  spongy  tissue  has  been  traversed  by  the  blade  of  the  chisel  it 
will  come  in  contact  with  the  opposite  wail  of  solid  outside  bone 
and  will  at  oncebe  felt  to  be  driven  with  greater  resistance.  Then, 
as  Macewen  remarks,  the  osteotome  acts  as  a  probe  as  well  as  a 
cutting  instrument.  The  bone  should  not  be  entirely  divided,  but 
when  it  seems  evident  that  only  a  shell  is  left,  attempt  should  be 
made  to  fracture  the  femur — very  little  force  is  needed,  and  if  the 
bone  does  not  yield  easily  the  chisel  should  be  again  driven  in  still 
further — always  loosening  it  after  each  blow  of  the  mallet,  and 
directing  the  blade  in  a  new  direction. 

The  bone  breaks  with  a  loud  snap,  and  in  most  cases  the  flexed 
leg  can  be  extended  and  the  adducted  one  brought  straight  and  no 
unnecessary  manipulation  of  the  bone  should  be  made.  Very  little 
force  is  needed  to  correct  the  deformity,  and  if  the  leg  does  not 
yield  to  gentle  force  then  the  best  obtainable  position  should  be 
taken  and  at  some  subsequent  time  rectification  should  be  com- 
pleted, There  is  little  bleeding  and  scarcely  any  skin  wound, 
unless  it  is  necessary,  as  sometimes  happens,  to  make  a  cut  in  the 
anterior  surface  of  the  upper  thigh,  to  divide  bands  of  contracted 
fascia  which  prevent  full  extension  of  the  thigh.  The  patient 
should  be  placed  on  a  bed  frame  and  a  light  extension  applied  to 
steady  the  leg.  This  mode  of  after-treatment  is  simpler  and  more 
comfortable  than  a  plaster  of  Paris  spica  bandage,  which  is  particu- 
larly objectionable  and  dirty,  and  which  does  not  allow  inspection 
of  the  leg  and  that  accurate  adjustment  which  is  possible  when  the 
hip  is  exposed  to  view. 

Confinement  to  bed  should  last  between  five  and  six  weeks.  If 
adduction  or  abduction  is  present  it  should  be  corrected  at  the 
time  of  operation  and  the  leg  retained  in  the  corrected  position; 
and  if  it  is  desired  to  compensate  for  slight  bone  shortening  it  can 
be  done  by  putting  up  the  shortened  leg  in  an  abducted  position. 
There  is  no  need  of  a  cuneiform  osteotomy  in  these  cases,  as  the 
simple  linear  cut  makes  rectification  of  the  lateral  deformity  as 
easy  as  the  correction  of  the  flexion.  The  risks  attending  the  ope- 
ration are  very  slight.  Hemorrhage  is  very  rare — although  acci- 
dents have  been  reported  from  pressure  on  the  femoral  vessels  by 
sharp  edges  of  bone.' 

Poore,^  in  his  admirable  book  on  osteotomy  and  osteoclasis,  has 
summarized  the  results  in  167  cases  of  osteotomy  about  the  upper 
end  of  the  femur  as  follows : 

^  Post  :    Ann.  Anat.  and  Surg.,  Jan.,  1883,  and  Rev.  de  Chir.,  Dec,  1881. 
=  C.  T.  Poore  ;    "  Osteotomy  and  Osteoclasis,"  New  York,  1884. 


////'   DISEASE.  337 


68  sections  throuL;li  tlic  neck, 

64  linear  sections  below  the  trochanters, 

35  cuneiform  sections, 


f  iired. 

Died. 

l-'ailures. 

5^> 

6 

6 

54 

6 

4 

28 

5 

2 

138  17  12 


giving  a  mortality  of  10.18  per  cent. 

This  is  misleading,  because,  as  he  points  out,  many  of  the  opera- 
tions belong  to  a  period  before  the  advent  of  antiseptic  surgery ;  of 
the  17  fatal  cases,  12  occurred  before  1877,  and  only  5  after  that 
date,  although  the  number  of  operations  performed  in  each  of  the 
two  periods  was  nearly  the  same.  Moreover,  many  of  the  cases 
were  operated  upon  altogether  too  soon  after  the  cessation  of 
active  symptoms.  To-day  with  the  increased  experience  in  the 
operation  and  the  better  understanding  of  the  indications  for  its 
performance,  the  operation  is  one  of  the  most  satisfactory  in  surgery, 
and  the  risks  of  suppuration,  fever,  or  untoward  results  are  hardly 
greater,  if  due  aseptic  precautions  are  used  than  those  encoun- 
tered in  an  ordinary  fracture  of  the  upper  part  of  the  thigh.  The 
ultimate  functional  results  following  the  operation  are  excellent. 
Although  there  is  no  motion  at  the  hip-joint,  the  lumbar  vertebrae 
are  usually  more  movable  than  is  normally  found.  The  operation 
is  indicated  in  all  cases  of  severe  deformity  where  the  distortion 
interferes  seriously  with  locomotion. 

Shortening  of  tJie  Limb. — Shortening  of  the  limbs  after  hip-joint 
disease  and  after  excision  occurs  in  a  certain  number  of  cases;  the 
shortening  is  not  limited  to  the  femur,  but  occurs  also  in  the  tibia 
and  fibula  and  the  foot.'  Nothing  can  be  done  to  prevent  this 
arrest  of  growth.  Prevention  of  the  development  of  the  disease 
and  such  use  of  the  limb  as  is  compatible  with  safety  of  the  joint 
(inducing  proper  circulation  in  the  limb)  may  be  regarded  as  the 
only  means  at  our  command. 

In  cases  with  subluxation  and  absorption  of  the  head  of  the 
femur  and  enlargement  of  the  acetabulum  the  deformity  entailed 
is  necessarily  permanent,  as  far  as  the  alteration  of  the  bone  is  con- 
cerned, but  the  accompanying  flexion  and  abduction  can  be  cor- 
rected. 

Patients  with  much  shortening  of  the  diseased  leg  vary  a  great 
deal  in  the  relief  afforded  by  a  high  shoe ;  sometimes  they  find  it 
of  the  greatest  possible  benefit,  while  at  other  times  it  is  a  constant 
annoyance  and  bother.  The  shoe  can  be  raised  by  a  cork  sole,  or 
more  cheaply  by  an  iron  patten. 

Double  Hip  Disease. — A  combination  of  hip  disease  with  tubercu- 

'  Wolff:    Berlin,  klin.  Wochenschr.,  1SS3,  No.  28. 
22 


338 


OR  THOPEDIC  S  UR  GER  V. 


and-pulley  method. 


lar  disease  of  another  joint,  is  occasionally  seen.  These  cases  can 
be  treated  by  a  combination  of  the  appliances  needed  for  each  joint 
affection.  Double  hip  disease  is  not  so  rare  as  might  be  supposed. 
Dr.  Ridlon,  of  New  York,  has  recently  reported  a  collection  of 
fourteen  cases,  and  cases  of  this  sort  are  not  infrequently  met  in 
hospital  clinics. 

In  treating  double  hip-joint  disease,  the  first  indication  is  to  pre- 
vent or  check  pain.  This  is  readily  done  by  the  ordinary  weight- 
But  with  this  method  it  is  impossible  to  carry 
the  patient  about,  an  indication  which  is 
particularly  important.  This  can  be  accom- 
plished readily  by  means  of  a  double  Thomas 
splint,  a  wire  cuirass,  or  more  conveniently 
by  the  use  of  the  oblong  bed  frame.  To  the 
latter  should  be  attached  arrangements  for 
traction  fastened  to  the  frame,  and  in  this 
the  patient  can  be  carried  about  readily 
with  thorough  fixation  at  both  joints.  This 
will  be  found  to  be  much  more  comfort- 
able than  the  wire  cuirass  or  the  Thomas 
hip  splint,  and  it  is  also  more  readily  ad- 
justed. The  chief  difficulty  in  treating  dou- 
ble hip  disease  is  in  the  prevention  of  de-. 
formity,  not  during  the  active  stage  of  the 
disease,  but  after  convalescence  has  been 
established. 

Deformity  will  not  occur  if  patients  are  kept  recumbent  for  a 
sufficiently  long  time  to  establish  a  perfect  cure.  If,  however, 
patients  are  allowed  to  walk  or  move  too  soon,  before  the  joints  are 
thoroughly  strong,  weight  must  necessarily  fall  upon  the  affected 
limbs  in  walking.  If  these  are  not  strong  enough  to  sustain  the 
weight,  deformity  will  ensue  and  occasion  great  annoyance.  This 
danger  can  be  avoided  by  keeping  the  patient  recumbent  a  suffi- 
ciently long  time.  Ultimate  recovery  with  a  certain  amount  of 
motion  at  one  or  both  hips  may  take  place,  but  locomotion  is  often 
possible,  although  the  gait  is  necessarily  awkward  and  limping. 


Fig.  324. — Patten  for  Use  in 
Shortened  Limbs. 


The  Operative  Treatment  of  Hip  Disease. 


The  subject  of  excision  of  the  joint  in  hip  disease  is  one  on  a 
question  of  great  practical  importance  and  has  excited  much  dis- 
cussion, especially  of  late  years.  The  early  history  of  the  opera- 
tion is  of  significance  in  defining  its  place,  as  Mr.  Marsh  has  recently 
pointed  out.  "  The  operation  of  excision  was  introduced,  about  forty 


////'  Disi'.yisr:. 


339 


years  ago,  by  Sir  Win.  Fcrgusson  and  liis  school.  At  this  date  com- 
paratively little  attention  had  been  j)aid  to  diseases  of  the  joints, 
which  frequently  grew  worse  and  worse  until  amputation  was  all 
that  remained.  Under  these  conditions  it  was,  as  it  was  hekJ  at  the 
time,  a  great  advance  in  conservative  surgery,  when  Fergusson  anfl 
his  contemporaries  resorted  to  excision  as  a  substitute  for  amputa- 
tion ;  but  although  excision  has  had  the  important  effect  of  largely 
diminishing  the  number  of  amputations  for  joint  disease,  it  rests  upon 
a  principle  which  many  confidently  anticipate  is  only  a  link  in  the 
chain  of  progress." '  With  the  improvement  in  the  conservative 
method  of  treating  the  disease,  it  is  to  be  expected  that  excision 
would  find  itself  in  a  changed  position.  So  that  although  resection 
of  the  hip  has  been  praised  as  a  measure  of  great  value  and  con- 
demned as  an  unjustifiable  proceeding,  no  general  agreement 
among  surgeons  can  be  said  to  have  yet 
been  reached  as  to  its  exact  value  as  a 
therapeutic  measure. 

The  operation  itself  is  not  a  difificult  one. 
A  straight  external  incision  (Fig.  325)  is  the 
one  most  commonly  used,  and  the  most  ser- 
viceable. The  original  T-shaped  incision  is 
useful  where  one  intends  an  extensive  oper- 
ation upon  the  pelvic  bones  as  well  as  the 
removal  of  the  head  of  the  femur.  It  is 
easy  to  add  the  transverse  incision  at  the 
top  or  middle  of  the  longitudinal  cut  if  it 
seems  necessary  at  any  stage  of  the  opera- 
tion. A  V-shaped  incision  employed  by 
Cheever  has  the  merit  of  allowing  a  careful  inspection  of  the  part. 

There  are  various  varieties  of  the  straight  incision  Avhich  are  advo- 
cated by  different  surgeons.  The  incision  as  described  by  Sayre  (Fig. 
326)  should  begin  at  a  point  midway  between  the  anterior  superior 
iliac  spine  and  the  great  trochanter,  the  knife  being  pushed  directly 
to  the  bone.  The  cut  should  curve  to  the  top  of  the  trochanter 
and  then  downward  and  forward,  the  length  of  the  incision  being 
from  four  to  eight  inches.  Ollier's  incision  (Fig.  327)  is  less  curved 
and  begins  four  fingers'  breadth  below  the  crest  of  the  ilium  and 
the  same  distance  behind  the  anterior  superior  spine  of  the  ilium. 
It  is  then  carried  down  to  the  top  of  the  trochanter  and  then 
follows  down  over  the  shaft  of  the  femur. 

Wright,  whose  experience  has  been  very  extensive,  finds  the  best 
incision  to  be  the  simple  longitudinal  one  known  as  Langenbeck's, 
over  the  middle  of  the  trochanter,  about  three   inches   long  and 


Fig.  325. 


'  Brit.  Med.  Journal,  July  20th,  1889,  p.  119. 


340 


OR  THOPEDIC  S  URGER  V. 


slightly  curved  backward.  The  tissues  should  be  incised  down  to 
the  bone,  and  above  the  trochanter  the  soft  parts  should  be  divided 
and  the  capsule  opened.  It  is  best  to  incise  the  periosteum  of  the 
trochanter,  and  if  possible  with  a  periosteum  elevator  to  free  it  with 
its  muscular  "attachments  from  the  bone.  Sometimes  the  whole 
trochanter  can  be  uncovered  in  this  way.  Oilier  advises  an  addi- 
tional detail,  which  consists  in  separating  the  great  trochanter,  with 
its  muscles  undisturbed,  and  then  turning  it  up  to  resect  the  head 
and  neck  of  the  femur  ;  he  then  replaces  the  trochanter,  hoping 
thus  to  obtain  better  power  in  the  limb. 

In  using  any  of  these  incisions,  after  having  then  made  the  cut 


Fig.  326. 


Fig.  327. 


down  to  the  outer  aspect  of  the  trochanter  and  separated  the  peri- 
osteum on  the  outer  side,  so  far  as  practicable,  the  next  step  is  to 
separate  the  soft  tissues  from  the  bone  on  the  inner  side,  stripping 
back  the  periosteum  as  far  as  it  exists  as  such.  In  advanced  cases 
of  hip  disease,  however,  it  will  be  found  that  all  that  it  is  practica- 
ble to  do  is  to  clear  the  periosteum  from  the  outer  aspect  of  the 
trochanter  and  then  to  separate  the  muscular  attachments  from 
the  neck  of  the  bone,  keeping  the  knife  as  close  to  the  bone  as  pos- 
sible. Then  passing  the  finger  around  the  femur  and  adducting 
the  leg  slightly,  will  raise  the  head  of,  the  femur  out  of  the  aceta- 
bulum, and  the  capsule  can  then  be  divided  and  the  head  of  the 
femur  thrown  out  into  sight  and  sawed  off,  or  the  section  can  be 
made  by  a  small  saw  before  dislocating  the  bone  if  the  finger  is 


////'    DISIiASI':. 


341 


kept  inside  of  the  neck  of  llu-  femur  as  a  guard.  If  section  is  made 
in  the  latter  way,  the  saw  should  pass  just  below  the  trochanteric 
margin.  If  the  head  of  the  bone  is  dislocated,  it  is  more  easy  to 
see  the  limit  of  diseased  bone  and  to  make  the  section  well  in  the 
healthy  tissue.  The  objection  to  dislocating  the  head  of  the  bone 
before  section  is  that  fracture  of  the  diseased  and  atrophied  shaft 
of  the  femur  may  occur  if  it  is  done  roughly,  and  also  periosteum 
may  be  stripped  up  from  the  inner  aspect  of  the  shaft  and  cause 
necrosis.  If  it  can  be  done,  on  the  other  hand,  the  condition  of  the 
head  and  neck  of  the  femur  can  be  much  more  accurately  deter- 
mined. When  once  excision  is  undertaken,  the  diseased  bone 
should  be  removed,  even  if  it  is  necessary  to  remove  several  inches 
of  the  shaft.  Where  the  head  is  adherent,  it  should  be  curetted  or 
chiselled  from  its  place,  as  has  been  done  by  Volkmann. 

The  acetabulum  should  be  examined  and  any  sequestra  removed 
and  any  carious  surface  should  be  scraped  with  a  Volkmann's^ 
spoon.  If  the  acetabulum  is  perforated,  the  edges  should  be 
chipped  ofY  until  the  point  is  reached  where  the  periosteum  lining 
the  pelvis  is  attached  to  the  bone.  It  is  a  difificult  matter  to  re- 
move all  of  the  tubercular  material  in  excision  of  the  hip ;  and  this 
must  necessarily  lead  to  relapses  and  imperfect  results  in  many 
cases.  The  mere  removal  of  the  head  of  the  bone  is  a  very  incom- 
plete measure  for  the  eradication  of  the  disease  in  those  cases 
where  the  tuberculous  material  has  infiltrated  all  the  tissues  in  the 
neighborhood  of  the  joint — tissues  which  cannot  possibly  be  thor- 
oughly removed. 

In  many  cases  of  extensive  disease  it  is  not  easy  to  do  a  sub- 
periosteal operation,  and  but  little  satisfaction  can  be  gained  by  any 
extensive  attempt  to  separate  the  periosteum  with  its  muscular 
attachments  from  the  bone.  In  the  severer  cases  the  capsule  is 
lax  and  partially  destroyed,  so  that  the  finger  when  first  introduced 
in  the  wound  finds  the  head  of  the  bone  only  loosely  in  contact 
with  the  acetabulum  and  dislocation  is  easily  accomplished.  The 
bleeding  from  the  operation  is  generally  trivial. 

Before  speaking  of  the  after-treatment  of  the  excision  wound,  it 
is  necessary  to  speak  of  several  other  incisions  recommended  for 
excision  of  the  hip. 

Heyfelder's  posterior  incision  is  advocated  by  Ashhurst.  This 
begins  a  little  above  and  behind  the  great  trochanter,  toward  which 
it  passes  in  the  line  of  the  fibres  of  the  gluteus  maximus,  and 
then  curving  around  and  behind  the  great  trochanter,  passes  down- 
ward and  backward,  ending  on  the  linea  aspera.  By  this  means  no 
muscular  fibres  are  divided  transversely. 

Roser  would  preserve  the  trochanter  by  making  an  anterior  in- 


342 


OR  THOPEDIC  S  UR  GER  V. 


cision  in  the  line  of  the  neck  of  the  femur,  beginning  just  outside 
of  the  crural  nerve  and  cutting  transversely  through  the  iliacus, 
the  rectus,  sartorius,  and  tensor  vaginae  femoris  muscles.  The  cap- 
sule is  divided  in  the  same  line,  and  the  head  of  the  femur  thrown 
out  of  the  wound  by  rotating  the  leg  outward.  The  same  end  can 
be  accomplished  by  the  longitudinal  anterior  incision  identified 
with  the  names  of  Hueter  in  Germany,  and  R.  W.  Parker  in  Eng- 
land, which  has  lately  come  into  much  notice. 

A  simple  straight  incision  is  made  from  just  below  the  anterior 
superior  spine  of  the  ilium  and  carried  downward 
and  slightly  inward  for  three  or  four  inches.  The 
upper  two-thirds  of  this  cut  should  reach  the 
femur,  the  lower  one-third  should  be  more  super- 
ficial. The  capsule  in  this  way  will  have  been 
divided  and  the  opening  into  it  can  be  enlarged. 
Then  with  a  narrow-bladed  saw  the  neck  of  the 
femur  is  divided  and  the  head  removed,  but  the  Y- 
ligament  should  be  left,  as  far  as  possible,  intact. 
It  is  said  that  the  anterior  incision  heals  as  well  as 
any 'and  that  there  is  no  trouble  about  drainage. 
The  writers  have  had  no  personal  experience  with 
the  method.  McNamara  has  excised  through  an 
incision  on  the  inner  side  of  the  thigh  near  the  in- 
sertion of  the  adductors. 

After  the  operation  a  tube  or  a  strip  of  gauze 
should  be  left  in  the  most  dependent  angle  of  the 
wound  and  the  rest  may  be  sewed  up  if  the  tissues 
are  not  too   much  infiltrated  with  the  products  of 
inflammation.     A  heavy  antiseptic  dressing  should 
then  be  applied  and  the  child  may  be  fixed  in  the 
gouttiere  cuirass,  or    a  posterior   wire    splint    de- 
FiG.  328 -Bed  Frame  scribcd  abovc,  or  a  Thomas  hip  splint,  or  a  bed 
for  Use  in  Excision  of  frame,  which    sliould   be  widened  at  the    hips    as 
'^'  shown   in   the   figure  to  allow  the  change  of  the 

dressings  without  altering  the  child's  position  or  disturbing  the 
joint.  Plaster  of  Paris,  here  as  in  osteotomy  of  the  hip,  is  a  dirty, 
uncomfortable,  and  generally  unsatisfactory  method  of  dressing. 

A  light  bed  extension  may  be  applied  to  steady  the  leg,  and  kept 
on  until  the  child  gets  up.  As  soon  as  it  can  be  done  without 
causing  pain,  the  child  should  get  up  and  go  about,  using  a  long 
traction  splint  at  first,  folloAved  by  the  use  of  a  protection  splint  of 
some  kind  for  months.  If  the  leg  be  used  too  soon,  the  condition 
of  the  joint  must  necessarily  prove  unsatisfactory,  for  shortening 
'  Barker:    Brit.  Med.  Journ.,  June  23d,  1888. 


////'    niShlASl'l. 


343 


and  displacement  are  almost  sure  tf)  follow  any  misuse  of  the  limb. 
Where  splints  are  not  readily  at  hand,  crutches  can  be  used  as  a 
substitute,  but  they  cannot  be  relied  upon  to  prevent  ultimate 
deformity. 

Rinne,"  after  excision  at  the  hip-joint,  attempts  to  avoid  the  re- 
sult of  a  cure  with  a  sinus  by  leavinjT  the  wound  open,  using  no 
sutures  and  leavint^  an  antiseptic  tampon  (t[  carbolic  gauze  in  the 
wound,  putting  on  iodoform.  On  the  first  dressings,  the  tampon 
should  not  be  removed,  but  left  to  be  pushed  out  by  granulation. 
In  ten  cases  treated  in  this  way,  seven  healed  without  a  sinus,  and 
none  had  formed  in  the  earliest  case  three  years  later,  and  in  the 
latest,  one  and  one-fourth  years.  In  all  of  the  cases  the  disease  at 
the  time  of  the  operation  was  well  advanced,  and  in  the  three  not 
healed  complications  existed.  Rinne  claims,  as  the  advantages  of 
the  method,  prompt  arrest  of  hemorrhage,  good  drainage,  complete 
juxtaposition  of  the  antiseptic  with  the  wound,  diminution  of  the 
pain  caused  by  pressure  of  the  upper  end  of  femur  against  the  pel- 
vis, and  a  solid  a-nd  firm  cicatrix. 

Schede,  after  excision,  places  the  limb  in  an  abducted  position  to 
anticipate  the  subsequent  tendency  to  adduction. 

If  it  is  desired  and  expected  to  secure  healing  of  the  wound 
without  the  formation  of  sinuses,  it  is  best  to  remove  the  drainage 
tube  at  the  end  of  24  to  'I16  hours  and  insert  a  small  gauze  tampon 
at  the  outlet  of  the  wound,  and  in  comparatively  early  excisions  first 
intention  should  be  aimed  at. 

It  would  seem  as  if  the  mortality  of  the  operation,  when  com- 
pared with  the  death  rate  after  conservative  treatment,  would  defi- 
nitely settle  the  place  of  the  operation,  but  on  both  sides  of  the 
question  the  various  groups  of  figures  lack  uniformity  and  the 
results  of  a  statistical  inquiry  are  even  less  satisfactory  than  usual. 
The  sam.e  is  in  a  measure  true  of  a  comparison  of  the  ultimate 
results  obtained  by  the  two  methods.  The  mortality  of  the  opera- 
tion cannot  fairly  be  judged  by  generalizing  from  the  results  of 
operation  before  the  introduction  of  antiseptic  surgery.  Leisrink's  - 
tables  of  operations  done  without  antiseptic  precautions  set  the 
death  rate  at  63.6  per  cent.  Culbertson  tabulated  418  cases  with 
41.6  per  cent  mortality.  Sayre's  75  cases  gave  34.7  per  cent.  These 
were  all  without  antisepsis. 

Caumont^  divided  his  cases  into  two  groups,  and  he  found  that 
before  antisepsis  the  death  rate  was  66  per  cent.,  while  with  anti- 
septic precautions  it  was  only  41  per  cent. 

'  Deutsche  Medicinische  Wochenschrift,  1SS4,  No.  20. 

^Arch.  f.  Kl.  Chir. ,  xii.,  177. 

3  Deutsch.  Z.  f.  Chir.,  xx. ,  1SS4,  344. 


344 


OR  THOPEDIC  S  URGER  V. 


Grosch '  has  collected  one  hundred  and  sixty-six  cases  of  this 
operation,  done  under  strict  antiseptic  precautions.  In  presenting 
the  cases  he  has  grouped  them  under  heads  corresponding  to  the 
condition  of  the  joint  at  the  time  of  the  operation.  The  first  stage 
he  classifies  as  that  where  the  pathological  change  is  slight,  and 
where  the  suppuration,  slight  in  amount,  has  not  worked  to  the 
outside.  In  the  second  stage  fall  those  cases  with  extensive  sup- 
puration and  established  fistulae.  The  third  class  comprises  those 
patients  who  have  become  much  reduced  by  prolonged  and  exten- 
sive disease.  Out  of  one  hundred  and  twenty  cases  watched  to  the 
end,  forty-four  died,  a  mortality  of  36.7  per  cent,  a  percentage 
which  corresponds  with  that  of  Guy's  Hospital,  Volkmann's  clinic, 
or  the  Copenhagen  clinique,  and  is  lower  than  Culbertson's  tables 
taken  from  cases  not  all  treated  antiseptically,  and  is  much  lower 
than  Leisrink's  mortality  before  the  introduction  of  the  antiseptic 
method,  64  per  cent.  Furthermore,  dividing  the  cases  into  two 
groups,  those  occurring  between  1870  and  1875,  during  the  appren- 
ticeship of  the  antiseptic  technique,  the  percentage  of  mortality 
was  9  per  cent  higher  than  since  that  time.  The  mortality  in  the 
first  stage  of  the  disease  among  children  was  o  per  cent,  in  the 
second  stage  24.1  per  cent,  and  in  the  third  67.5  per  cent.  Anti- 
septic dressings  do  not  seem  to  have  effected  any  change  as  to  the 
usefulness  of  the  cured  limb  as  compared  to  that  before  the  method 
was  introduced.  This  is  a  matter  which  is  not  yet  definitely  set- 
tled, but  a  number  of  cases  were  established  where  an  almost  nor- 
mal usefulness  of  the  limb  had  remained  unimpaired  many  years 
after  the  operation. 

Where,  during  the  operation,  perforation  of  the  acetabulum  oc- 
curred, the  percentage  of  mortality  increased  twenty  per  cent. 

Grosch  further  found  that  the  duration  needed  for  recovery  was 
not  influenced  by  the  antiseptic  method  of  dressing,  but  it  gave 
a  greater  immunity  against  wound  complications. 

Results  in  Excision  of  the  Hip-Joint. — Elben  -  reports  the  analysis 
of  results  in  three  hundred  and  eighty-eight  cases  of  excision  of 
hip-joint  for  coxitis.  One  hundred  and  eighty-four  died ;  seventy- 
five  did  not  remain  under  observation.  Of  the  living,  in  sixty-one 
only  were  the  ultimate  results  as  to  the  usefulness  of  the  limb  as- 
certained. Of  these,  forty-one  were  able  to  walk  without  an  ap- 
paratus, fifteen  needed  an  apparatus,  and  five  had  no  use  of  the 
limb. 

The  following  groups  of  cases  are  reported  when  the  operations 
were  entirely  aseptic. 

^  Cent.  f.  Chir.,  18S2,  14,  p.  229.  ^  Centralblatt  f.  Chin,  2,  77. 


jiir  Disi-.ASi-:. 


345 


Cases 

I'cr  cent. 

48 

25-30 

33 

48.5 

166 

Z^>-7 

3^^ 

30.5 

Volkmann/ .  .... 

Korff;-'        ...... 

Grosch,3     ,...,. 
Alexander,         . 

Wright  has  tabulated  2,461  cases,  new  and  old  all  together,  and 
finds  1,566  recoveries  and  841  deaths,  or  34  per  cent  mortality. 
None  of  these  statistics  are  of  very  great  value  because  they  are  from 
different  writers,  who  estimate  the  results  by  different  standards, 
and  some  observe  the  cases  for  many  years,  while  others  estimate 
only  the  proximate  mortality.  Most  of  them,  moreover,  are  from 
a  partisan  standpoint,  either  attacking  or  defending  the  operation. 

The  Clinical  Society  committee,  analyzing  a  smaller  number  of 
cases  (45),  found  that  the  deaths  were  as  follows: 

Per  Cent. 
Resulting  from  operation,   .....      15.6 


Tubercular  disease, 

"  meningitis, 

Albuminoid  disease,     . 
Intercurrent  disease,    . 


9.0 

4.4 
6.6 
4.4 

40.0 


In  these  cases,  as  in  fatal  cases  where  excision  is  not  performed, 
the  deaths  are  due  chiefly  to  tubercular  infection  of  the  lungs  or 
cerebral  meninges,  to  progressive  caries,  or  to  amyloid  changes  in 
the  viscera. 

The  claim  that  excision  of  the  hip  is  a  preventive  of  systemic  in- 
fection, is  one  of  such  importance  that  it  demands  investigation; 
for  if  this  is  the  case,  the  operation  has  a  value  apart  from  its 
purely  surgical  aspect.  That  general  tuberculosis  and  tubercular 
meningitis  supervene  in  a  certain  proportion  of  cases  of  hip  disease 
is  a  fact  well  known.  In  the  Alexandra  Hospital  from  1867  to 
1879,  there  were  23  deaths  from  tubercular  meningitis  in  384  cases 
of  hip  disease,  there  were  in  these,  260  suppurating  cases  with  16 
deaths  (6.15  per  cent),  and  124  cases  with  7  deaths  (5.6  per  cent). 
In  these  cases  the  treatment  was  conservative  throughout.  The 
risk,  therefore,  is  a  small  one  even  in  serious  suppurative  cases 
treated  conservatively.  Considering  groups  of  cases  treated  b}-  ex- 
cision, Mr.  Croft  reported  45  cases  with  a  mortality  of  4.4  per  cent 
from  tubercular  meningitis,  while  Mr.  Wright  in  100  cases  had  only 
I  death   from  general  infection.     But  these   operative   cases  were 

'  Verhdl.  d.  Deutsch.  Ges.  f.  Chir.,    1S77,  59. 

=  Deutsch.  Z.  f.  Chir,  xxii.,  149.  3  Cent.  f.  Chir.,  1SS2,  p.  22S. 


346  ORTHOPEDIC  SURGERY. 

probably  under  observation  for  a  shorter  time  than  the  conservative 
cases  above  noted. 

On  the  other  side,  Konig/  speaking  from  a  very  large  experience 
in  excisions,  stated  that  the  hope  of  immunity  from  tubercular  in- 
fection had  not  been  gained  by  resection,  even  by  antiseptic  resec- 
tion. Of  21  hip  excisions,  47.6  per  cent  had  died  of  tuberculosis  in 
4  years,  and  his  experience  was  the  same  in  the  resection  of  other 
joints. 

Caumont  found  no  preventive  effect  in  his  cases  of  resection. 
Of  26  cases  treated  conservatively,  one-fifth  died  of  tubercular 
disease;  while  of  12  cases  resected,  one-third  died  of  tubercular  in- 
fection. Mr.  Barker,  a  warm  advocate  of  excision,  in  his  lecture  at 
the  Royal  College  of  Surgeons  in  1888  on  the  treatment  of  tubercu- 
lous joint  disease,  said  that  in  no  less  than  10  per  cent  of  all  deaths 
following  excision  "  rapid  miliary  tuberculosis  supervened  in  such 
a  way  as  to  suggest  strongly,  if  not  to  prove,  that  the  surgical  in- 
terference was  the  cause  of  the  generalization  of  the  disease." 

In  any  operation  upon  a  tubercular  joint,  it  must  be  borne  in 
mind  that  the  risk  of  what  is  called  "  operative  tubercular  infec- 
tion "  is  added  to  the  risk  of  the  disease.  The  statistics  of  Wart- 
mann,  based  upon  837  resections,  show  that  at  least  10^  of  all  the 
deaths  are  caused  by  rapid  general  miliary  tuberculosis,  coming 
on  in  such  a  way  that  it  is  strongly  suggested  that  the  surgical 
interference  stood  in  a  causative  relation.  This  point  has  been  of 
late  often  alluded  to,  and  the  lesson  to  be  drawn  is,  that  in  exci- 
sions the  work  should  be  done  cleanly,  with  as  little  tearing  of  tissue 
and,,  opening  of  lymphatics  as  may  be,  with  the  most  careful  and 
constant  irrigation.  It  may  be  stated  then,  in  brief,  that  resection 
of  the  hip-joint  as  an  operation  is  attended  by  an  immediate  fatality 
of  about  7  per  cent.  The  mortality  of  the  disease  after  the 
operation  cannot  be  estimated  as  less  than  35  to  45  per  cent,  and 
where  cases  are  followed  up  for  several  years  it  is  higher  still,  as 
in  the  cases  of  Caumont,  where  it  was  62  per  cent.  The  operation 
does  not,  so  far  as  one  can  judge  from  statistics,  lessen  the  likeli- 
hood of  tubercular  disease  elsewhere. 

Besides  the  cases  which  are  fatal  and  those  to  be  classed  as  re- 
coveries, there  is  this  long  series  of  cases  in  Avhich  the  wounds  do 
not  heal  nor  does  the  leg  become  useful.  Leisrink  classed  12.5  per 
cent  of  his  cases  as  "  unhealed  "  and  Holmes  speaks  of  26.5  per  cent 
as  "  failures."  In  the  matter  of  relapses,  Yale  would  set  the  per- 
centage at  not  less  than  20  from  his  personal  experience,  and  he 
quotes  Neuber  as  saying  that  about  half  of  his  cases  have  relapsed. 

'  Archiv  f.  Klin.  Chir. ,  xxvi.,  822. 


////'    niSF.ASl'.. 


347 


Nearly  all  of  these  limbs  are,  of  course,  useless  as  regards  their 
function. 

An  analysis  of  lOO  cases  of  excision  of  tlie  lii^j  by  Mr.  Wright 
gives  the  following  results,  up  to  the  time  at  which  the  patients 
were  last  seen:  ly  soundly  healed,  57  unhealed,  13  dead,  5  dying  or 
going  down-hill,  2  in  a  bad  condition,  1  might  need  amputation,  4 
had  undergone  amputation,  i  recent  case  doing  well.  As  this  table 
includes  just  100  cases,  the  percentage  results  are  apparent  at  a 
glance. 

Now  as  all  these  cases  occurred  within  the  last  ten  years,  that 
is,  since  the  management  of  wounds  has  been  so  much  improved, 
and  as  they  were  in  the  hands  of  a  surgeon  of  well-known  ability 
and  ample  experience,  it  does  not  seem  as  if  they  can  be  regarded 
as  affording  strong  evidence  in  favor  of  excision ;  for,  of  the  whole 
number,  ly  only  were  satisfactory,  that  is,  had  healed;  and  against 


Fig.  329.— Unfavorable  Result  in  a  case  of  Excision  of  the  Left  Hip  some  Years  after  Excision. 

these  successes  must  be  placed  17  in  which  the  operation  had  com- 
pletely failed,  that  is,  there  were  13  deaths  and  4  amputations;  and 
8  in  which  there  seemed  no  hope  that  failure  could  be  averted,  for 
5  were  reported  to  be  dying,  or  going  down-hill,  2  were  in  a  bad 
condition,  and  i  was  reported  as  a  case  in  which  amputation  might 
be  required.  In  other  words,  while  17  per  cent  were  successful  in 
regard  to  sound  healing  of  the  wound,  25  per  cent  ended  in  failure, 
and  the  remaining  57  (one  case  being  excluded  as  too  recent  to  be 
classified)  were  still  unhealed.  In  many  of  these  the  patients  were 
in  good  health,  and  the  wound  appeared  to  be  merely  superficial, 
and  discharge  was  slight;  but,  on  the  other  hand,  in  several  dis- 
charge was  free,  and  the  general  health  defective.  In  short,  any 
one  who  studies  these  cases  will  be  driven  to  the  conclusion  that 
about  20  per  cent  were  successful  and  that  about  80  per  cent  were 
unsatisfactory. 

Even  in  early  excision  where  one  would  expect  highl}-  favorable 


348  ORTHOPEDIC  SURGERY. 

results  if  anywhere,  the  ultimate  results  seem  disappointing,  for  in 
these  100  cases  of  Mr.  Wright's  there  are  30  in  which  the  disease 
had  been  in  progress  either  nine  months  or  less  than  nine  months 
when  excision  was  performed,  the  average  period  being  six  months, 
so  that  they  afford  us  some  information  as  to  the  ultimate  results 
of  early  excision,  a  point  upon  which  evidence  is  at  present  very 
meagre.  Of  these  30  cases,  i  died  of  pyaemia,  i  died  of  measles 
and  tuberculosis,  i  died  of  exhaustion,  i  was  dying  of  lardaceous 
disease,  and  2  underwent  amputation ;  that  is  to  say,  6  (20  per  cent) 
entirely  failed;  6  (20  per  cent)  healed  soundly;  7  (20  per  cent) 
were  unhealed  at  the  end  of  one  year;  6(20  per  cent)  were  un- 
healed at  the  end  of  two  years;  5  (20  per  cent  about)  were  too 
recent  to  be  classified;  that  is,  omitting  the  5  recent  cases,  about 
20  per  cent  were  successful,  and  20  per  cent  ended  either  in  death 
or  amputation  of  the  limb,  and  another  40  per  cent  were  unsatis- 
factory.' 

Mr.  Marsh  has  arranged  the  earlier  of  his  cases  treated  conserva- 
tively so  that  they  may  be  compared  with  similar  cases  which  were 
excised  by  Mr.  G.  A.  Wright,  whose  figures  have  already  been  re- 
ferred to.  Considering  the  earlier  of  ^6  cases  discharged  from  the 
Alexandra  Hospital  more  than  a  year  previously,  Mr.  Marsh 
says : ^ 

"  If  we  now  take  out  the  33  cases  which  were  admitted  within 
nine  months  of  the  onset  of  the  disease — the  average  duration 
being  six  months — we  find  that  16,  that  is  about  half,  suppurated, 
and  17  did  not  suppurate.  Of  the  16  cases  that  suppurated  (two 
were  double  cases)  the  general  result  was:  2  excellent,  5  good — not 
quite  50  per  cent ;  9  moderate,  a  little  more  than  50  per  cent. 

''As  to  Shortening  of  the  Limb. — 7  had  under  i  inch,  4  between  i 
and  2  inches,  i  was  2'%,  inches,  i  was  3;^  inches,  i  was  4  inches;  2 
were  double  cases.     Average  shortening,  i^^  inch. 

''As  to  Movement. — 5  had  free  movement,  4  had  slight  movement, 
7  Avere  fixed,  i  not  noted ;   i  was  a  double  case. 

"As  to  Power  of  Walking. — 11  walked  well,  5  walked  indifferently. 
"Of  the  17  non-suppurating  cases  among  the  early  admissions,  the 
general  result  showed  that  7  were  perfect  recoveries,  4  were  excel- 
lent, 4  were  good — 88  per  cent;  2  were  moderate — 12  per  cent. 

"As  to  Shortening. — 4  had  no  shortening;  7  under  i  inch,  5  be- 
tween I  and  2  inches,  i  was  a  double  case.  Average  shortening, 
half  an  inch. 

"As  to  Movement. — 5  had  perfect  movement,  5  had  free  movement, 
2  had  slight  movement,  4  were  fixed,  2  were  not  noted,  i  was  a 
double  case. 

'  Clin.  Soc.  Trans.,  vol.   xiv.  ^  Brit.  Med.  Journal,  Aug.  3d,  1889. 


jur  I)Isi-:ase.  349 

^^As  to  Power  of  Walking. —  7  were  ])crf(;ct,  9  walked  well,  i  walked 
indifferently. 

"If  we  compared  the  results  obtained  in  the  16  cases  of  suppura- 
tion in  which  the  patients  had  been  admitted  within  nine  months  of 
the  commencement  of  the  disease,  with  the  cases  in  which  Mr. 
Wright  excised  the  joint  within  nine  months  after  the  disease  set 
in,  we  see  that  whereas,  of  the  excision  cases,  20  per  cent  entirely 
failed,  20  per  cent  were  unhealed  a  year  afterward,  and  20  per  cent 
two  years  afterward  (the  remaining  20  per  cent  being  too  recent 
for  classification);  in  the  cases  of  non-excision,  all  the  sinuses  had 
healed  soundly,  and  the  general  result  was  satisfactory,  the  patients 
being  able  to  walk  well,  on  a  limb  shortened,  on  the  average,  by  only 
i^  inch. 

"  The  average  duration  of  the  37  cases  of  suppuration  up  to  the 
time  at  which  all  symptoms  of  disease  disappeared  and  the  chil- 
dren were  walking  freely  on  the  limb  and  without  crutches — that 
is,  until  they  were  apparently  finally  cured — was  a  little  under  5 
years.     In  the  non-suppurating  cases  it  was  just  over  3  years. 

"  I  think  it  important  and,  also,  only  right,  to  make  a  distinct 
statement  as  to  the  time  occupied  in  recovery  in  these  two  sets  of 
cases;  those,  namely,  in  which  the  disease  had  progressed  to  sup- 
puration, and  in  many  of  which  it  had  advanced,  almost  without 
treatment,  for  upward  of  a  year;  and  in  those  in  which  the  disease 
had  been  adequately  treated  before  suppuration  occurred.  I  think 
it  important,  first,  in  order  that  all  possible  care  may  be  taken  with 
the  early  treatment ;  and,  secondly,  because  it  is  desirable  to  have 
clear  data  upon  which  to  found  prognosis,  and  to  regulate  the 
period  during  which  treatment  must  be  carried  out ;  for  undoubt- 
edly many  cases  relapse  and  end  badly  because  sufficient  time  is 
not  allowed." 

Usefulness  of  the  Limb  after  Resection. — After  excision  of  the  hip- 
joint  the  mechanical  conditions  are  not  favorable  to  the  formation 
of  a  firm  joint.  After  operation  the  head  of  the  femur  is  gone  and 
part  or  all  of  the  neck.  The  capsular  ligament  is  destroyed  and  the 
upper  end  of  the  femur  lies  loosely  against  the  ilium — perhaps  at 
the  acetabulum,  perhaps  somewhere  else,  and  out  of  this  very  un- 
certain contact  a  new  joint  must  be  formed  if  there  is  to  be  one, 
or  else  a  union  without  motion.  A  new  joint  is  established  in 
successful  cases,  as  has  been  shown  by  Kuster,  Sayre,  Israel,  \\'ood- 
ward,  and  others. 

In  these  cases  a  synovial  sac  may  develop,  and  the  head  of  the 
bone  is  bound  firmly  to  the  ilium  so  that  a  comparatively  useful 
hip-joint  remains.  Such  a  case  is  figured  in  the  frontispiece  of 
Sayre's  "  Orthopedic  Surgery  "  (Second  Edition\  where  there  has 


350 


ORTHOPEDIC  SURGERY. 


been  a  formation  of  new  cartilage  and  new  fibrous  tissue.  In  cer- 
tain cases  the  functional  result  is  excellent,  both  as  to  motion  and 
stability;  but  such  cases  are  not  readily  obtained  under  such  un- 
favorable mechanical  conditions  for  the  establishment  of  a  stable 
joint  as  exist  after  the  removal  of  the  head  of  the  femur.  It 
should  be  borne  in  mind  that  motion  at  the  hip-joint  is  of  very 
little  importance  when  compared  to  stability.  The  extreme  mobil- 
ity of  the  lumbar  spine  in  cases  where  the  hip  is  ankylosed  quite 
compensates  for  loss  of  motion  at  the  hip,  when  the  limb  is  fixed  in 
good  position.  In  some  instances  a  limb  which  was  in  excellent 
condition  immediately  after  the  operation  becomes  ultimately  en- 
tirely useless.     An  illustration  of  this  was  reported  by  the  writers 

{New  York  Med.  Jo7ir?ial,  April,  1879) 
in  a  patient  seen  five  years  after 
excision.  In  Culbertson's  tables 
(Transactions  Am.  Med.  Asso.,  1876, 
p.  142)  the  case  is  reported  as  fol- 
lows :  ''  (No.  464.) — Recovered  in  six 
and  two-thirds  months  ;  one-half  inch 
shortening,  almost  perfect  motion. 
Last  heard  from  six  and  two-thirds 
months."  Though  the  limb  at  the 
time  of  the  patient's  reported  con- 
dition of  cure  was  in  a  favorable 
condition,  live  years  later  the  boy 
could  only  touch  the  floor  with  the 
toes  of  his  affected  limb,  and  was 
unable  to  walk  without  crutch  or 
.  ,,      ^       ,,   x^     ,     .  V,     cane    and    could    bear    little    or    no 

Fig.  330. — A  Very  liavorable  Result  of   Ex- 
cision of  the  Right  Hip,  showing  the  amount  of  weight  on  the  affected  limb. 

^°''°"-  It  is   difficult    to    determine    defi- 

nitely how  large  a  proportion  of  useful  limbs  ultimately  result  in 
cases  where  recovery  has  taken  place  after  excision  of  the  hip. 
Elben '  traced  out  61  cases  and  found  that  41  could  walk  without 
any  apparatus,  15  could  walk  only  by  the  aid  of  apparatus,  and  5 
could  not  walk  at  all.  The  Clinical  Society's  committee  investi- 
gated very  carefully  12  cases  which  were  cured.  Two  could  stand 
and  hop  on  the  excised  limb,  four  could  stand  firmly,  four  were 
able  to  stand  but  not  firmly,  2  could  not  stand.  The  functional  re- 
sults under  antisepsis  are  no  better  than  they  were  before  (Grosch). 
Mr.  Holmes  concludes:"  "The  limb  is  hardly  ever  so  firm  or 
powerful  in  walking  (after  excision)  as  we  constantly  see  that  it  is 
after  the  natural  cure  by  ankylosis,  nor  is  the  patient  so  active  or 


'  Cent.  f.  Chir.,  1879,  No.  2. 


=  Med.  Times  and  Gaz.,  Nov.  3d,  1877. 


7TI1>  n/SJCASK,  351 

enduring."  The  committee  of  the  Clinical  Society  reported  in 
regard  to  excision  of  the  hip  joint,  "that  movement  is  more  fre- 
quently present,  and  is  also  more  extensive  in  the  former  class  (of 
excision);  but  that  patients  often  walk  insecurely  and  with  consid- 
erable limp;  while  the  limb  after  treatment  by  rest  and  extension, 
though  frequently  more  or  less  fixed,  is  more  firm  and  useful  for 
purposes  of  progression.' 

Shortening  necessarily  results  after  resection.  In  all  probability  ' 
the  shortening  of  the  limb  after  conservative  treatment  is  less  than 
after  resection,  but  this  is  a  matter  which  cannot  be  readily  deter- 
mined. Mr.  Croft  estimates  that  the  shortening  of  the  limb  is 
only  a  trifle  more  than  it  is  in  the  most  favorable  cases  of  ankylosis 
after  destructive  disease  of  the  joint.  In  the  13  of  Mr.  Croft's  45 
cases  in  which  measurements  are  given,  the  average  shortening  was 
two  inches  and  three-quarters;  while,  in  the  Alexandra  Hospital 
cases,  in  24  good  cures  (after  suppuration)  the  shortening  was  one 
inch  and  a  quarter;  in  2  (also  after  suppuration)  there  was  no  short- 
ening, and  in  7  moderate  cures  the  average  was  three  inches  and  a 
quarter.  Here  the  balance  is  in  favor  of  non-excision ;  for  though  in 
7  cases  the  average  shortening  exceeded  that  in  Mr.  Croft's  13  cases 
by  half  an  inch,  yet  in  26  cases  of  non-excision  the  shortening  was 
less  than  half  the  average  amount  in  Mr.  Croft's  excision  cases.  In 
Mr.  Wright's  100  cases  of  excision,  the  shortening  is  given  in  only 
30.  In  them  the  average  amount  was  only  one  inch  and  a  half,  and 
this  must  be  accounted  as  a  very  favorable  showing. 

It  has  been  claimed  that  time  is  saved  by  excision,  and  in 
many  instances  this  is  undoubtedly  true;  but  in  severe  cases 
after  excision  of  the  hip,  as  after  other  excisions,  the  operation 
itself,  so  far  from  arresting  a  carious  process,  seems  to  prolong  it. 
This  is  particularly  true  after  excision  of  the  hip,  where  a  complete 
removal  of  all  tubercular  tissue  is  difificult.  The  after-treatment 
of  excision  is  moreover  a  matter  requiring  much  time  and  care. 
Union  at  the  hip-joint  is  a  result  v\diich  comes  only  after  the  lapse 
of  months,  and  protection  to  the  joint  and  a  certain  amount  of  fix- 
ation are  necessary  meantime.  To  allow  too  early  a  use  of  the 
leg  renders  a  good  result  very  unlikely.  The  use  of  some  fixation 
splint  or  of  a  fixation  and  traction  splint  is  advisable  for  several 
months,  and  confinement  to  bed  after  the  operation  should  be  as 
brief  as  possible. 

In  comparing  the  results  of  conservatism  with  those  after  excision, 
the  difficulty  is  such  that  the  results  of  conservative  treatment  have 
not  been  thoroughly  investigated.  From  those  which  have  been 
collected,  it  would  appear  that  the  mortality  following  conserv- 

'  Clin.  Soc.  Trans.,  xiv. ,  p.  234. 


352 


ORTHOPEDIC  SURGERY. 


ation  is  less  than  that  after  operation,  and  even  in  severe  cases,  the 
difference  in  favor  of  resection  is  not  as  great  as  has  been  sup- 
posed. Cazin,  Howard  Marsh,  C.  F.  Taylor,  Yale,  Dhourdin,  Hue- 
ter,  Judson,  and  Shaffer  and  Lovett  have  all  investigated  the  matter, 
as  has  been  already  shown  under  the  heading  of  prognosis. 

Exaggerated  statements  of  the  value  of  hip  excision  are  often 
made  by  general  surgeons  who  have  not  gained  an  extended  ex- 
perience in  the  value  of  thorough  conservative  treatment,  some 
going  so  far  as  to  say  that  the  presence  of  suppuration  indicates 
a  complication  which  demands  radical  measures.  In  the  39  cured 
cases,  investigated  by  Shaffer  and  Lovett,  where  only  conservative 
treatment  was  followed,  27  had  one  or  more  abscesses  in  the  course 
of  the  disease,  and  12  had  none;  and  the  following  table  will  show 
that  the  presence  of  abscess  not  only  did  not  prevent  a  cure,  but 
in  two  cases  a  cure  took  place  with  perfect  motion  at  the  joint. 

Table  Showing  the  Influence  of  the  Presence  or  Absence  of  Abscess 

UPON  Joint-Motion. 


Condition  of  Joint  as  Regards  Rlotion. 


No  motion  in  joint . . 

Slight  motion 

10°  to  45°  of  motion. 

90°  of  motion 

Perfectly  free  motion 


One  or  More 
Abscesses. 

No  Abscess. 

Total. 

Cases. 

Cases. 

Cases. 

12 

4 

16 

4 

2 

6 

5 

2 

7 

3 

3 

2 

I 

3 

Indications  for  Resection. — The  report  of  the  committee  of  the 
Clinical  Society  of  London  appointed  to  investigate  the  subject  in 
1880,  gives  certain  indications  for  excision  which  are  of  interest. 

"As  to  the  indications  for  resorting  to  the  operation  of  excision, 
there  are  certain  conditions  which  when  developed  in  the  course 
of  hip  disease,  either  preclude  recovery  or  make  recovery  improb- 
able unless  some  operative  interference  is  adopted."  These,  in  the 
opinion  of  the  committee,  are: 

"  I.  Necrosis,  and  separation  of  the  entire  head  of  the  femur  and 
its  conversion  into  a  loose  sequestrum. 

"  II.  The  presence  of  firm  sequestra,  either  in  the  head  or  neck  of 
the  femur,  or  in  the  acetabulum. 

"  III.  Extensive  caries  of  the  femur,  or  of  the  pelvis,  leading  to 
prolonged  suppuration  and  the  formation  of  sinuses. 

"  IV,  Intra-pelvic  abscesses  following  disease  of  the  acetabulum. 

"  V.  Extensive  and  old-standing  synovial  disease  and  ulceration  of 
the  articular  cartilages,  with  persistent  suppuration. 

"IV.  Displacement  of  the  head  of  the  femur  on  the  dorsum  ilii, 
with  chronic  sinuses  and  deformity. 


////'  JilSICASE.  353 

"  With  respect  to  the  general  question  of  operative  interference, 
the  committee  are  of  opinion  that  the  effect  of  complete  rest  and 
weight  or  other  modes  of  extension,  and  the  withdrawal  of  matter, 
should  always  be  patiently  tried  in  the  first  instance,  and  that  ope- 
rative interference  should  be  resorted  to  only  when  these  means 
have  failed  to  secure  the  favorable  progress  of  the  case." 

In  contrast  to  this  opinion  that  of  Mr.  G.  A.  Wright,  of  Man- 
chester, in  his  admirable  book  "  On  Hip  Disease  in  Childhood  "  may 
be  quoted.  The  writer  says  that  the  indication  for  excision  is  sup- 
puration. "Treatment  short  of  excision,  when  once  suppuration 
occurs,  is  useful  only  as  a  palliative  or  a  means  of  temporizing." 

The  statements  made  by  Sayre  and  Yale,  though  favorable  to  the 
usefulness  of  resection  of  the  hip,  are  much  more  conservative  than 
this,  and  claim  only  that  the  procedure  should  be  used  as  a  last 
resort. 

In  attempting  to  reconcile  these  contradictory  opinions,  it  must 
be  borne  in  mind  that  the  ultimate  results  after  early  excisions 
(before  extensive  destruction  in  the  bone  has  taken  place)  are 
much  more  favorable  than  after  late  excision,  as  has  been  shown  in 
the  figures  of  Grosch.  Where  a  late  excision  is  done,  the  surgeon 
will  always  regret  that  the  operation  had  not  been  done  before. 
The  results  of  careful  conservative  treatment,  if  carried  out  for  a 
long  time,  are  superior  to  those  after  excision  in  a  majority  of  cases, 
and  where  conservative  treatment  is  practicable  it  should  be  pre- 
ferred. In  large  hospitals  or  among  a  poor  and  unintelligent  class, 
conservative  treatment  is  sometimes  impracticable,  and  in  such 
cases  excision  is  resorted  to  earlier  than  would  otherwise  be  justi- 
fiable, and  the  "results  gained  are  more  satisfactory  than  when  the 
operation  is  deferred. 

It  must  be  evident,  in  comparing  the  mortality  and  the  results  of 
excision  of  the  hip  with  the  mortality  and  the  results  of  conserva- 
tive treatment,  that  excision  has  no  place  in  the  routine  treatment 
of  the  disease,  because  its  mortality  is  higher  and  its  functional 
results  inferior.  The  operation  has,  however,  a  decided  usefulness 
in  late  cases  of  hip  disease,  when  it  becomes  distinctly  a  life-saving 
procedure,  and  in  severe  cases  at  an  early  stage  Avhere  no  home 
treatment  or  adequate  hospital  treatment  for  a  long  time  is  practic- 
able. 

Although  the  writers  have  been  able  to  gain  thoroughly  satisfac- 
tory results  after  excision  of  the  hip,  and  in  a  few  instances  have 
had  reason  to  regret  not  having  resorted  earlier  to  excision  in 
cases  where  conservative  treatment  proved  unsatisfactory,  yet  after 
several  years'  careful  experience  in  the  treatment  of  hip  disease  by 
both  conservative  and  operativ^e  methods  they  would  unhesitatingly 
23 


354 


OK  THOPEDIC  S  UR  GER  V 


record  their  opinion  that  the  conservative  method  of  treatment  is 
preferable  to  the  operative  and  that  resection  is  needed  only  in 
exceptional  cases.  They  further  believe  that  resection  will  be  still 
more  rarely  needed  if  cases  can  be  thoroughly  treated  by  proper 
conservative  treatment. 

Other  operative  procedures  can  be  spoken  of  very  briefly. 

Trephining  into  the  head  of  the  bone  was  proposed  by  Fitzpat- 
rick  in  1867,  who  trephined  for  a  short  distance  into  the  great  tro- 
chanter arid  then  attempted  the  destruction  of  the  diseased  focus 
in  the  head  of  the  femur,  by  treating  the  bottom  of  the  cavity  thus 
made  by  inserting  a  stick  of  potassa  cum  calce.  Stoker  more  re- 
ently  has  revived  the  method,  except  that  he  trephines  well  into 
the  head  of  the  femur  and  then  uses  a  curette  freely.  MacNamara 
and  Greig  Smith  accomplish  the  same  end  by  tunnelling  info  the 
head  of  the  femur  with  a  drill  or  gouge  and  evacuating  any  tuber- 
cular material  there.  The  operation  is  a  most  serviceable  one  and 
often  affords  much  relief.  It  is  especially  indicated  in  acutely 
painful  conditions  of  the  joint,  as  it  relieves  tension  and  affords 
drainage.  In  a  case  recently  under  the  care  of  the  writers,  pain 
and  night  cries  were  relieved  by  it,  and  the  condition  of  the  patient 
improved  for  some  months,  but  the  ultimate  result  was  unfavora- 
ble. The  operation,  as  described  by  Stoker,  is  performed  most 
simply  by  exposing  the  outer  surface  of  the  trochanter  and  with 
a  small  trephine  boring  inward  and  slightly  upward,  in  the  direc- 
tion of  the  neck  of  the  femur.  It  must  be  estimated  in  each  case 
how  far  it  is  desirable  to  go  with  the  trephine  without  doing  too 
much  damage  to  the  joint.  Then,  with  a  curette,  the  operator  evac- 
uates any  carious  bone  found  at  the  bottom  of  the  trephine  hole, 
and  leaves  a  drainage  tube  running  to  the  bottom  of  the  wound. 

Incision  of  the  Joint. —  Incision  into  the  hip-joint  is  of  use  some- 
times in  checking  uncontrollable  night  cries,  and  in  cases  of  ex- 
quisite sensitiveness  of  the  joint  where  tension  of  the  capsule  may 
be  supposed  to  exist.  A  straight  incision  is  made  behind  the  tro- 
chanter major,  and  after  the  division  of  the  muscles  the  finger  can 
be  thrust  down  to  the  joint,  and  on  it  as  a  director  the  capsule 
can  be  opened.  In  two  cases  reported  recently,'  improvement  fol- 
lowed the  incision.  In  the  event  of  incising  the  hip-joint,  it  is  de- 
sirable to  remove  by  a  curette  any  diseased  and  softened  bone 
which  may  be  within  easy  reach.  The  benefit  from  simple  incision 
will  not  be  found  to  be  great  in  severer  cases. 

Ignipunctiire  or  cauterization  of  the  diseased  tissue  is  advocated 
by  Kolomnin,''  especially  in  "  femoral  coxalgia  "  (a  distinction  which 

^  E.  H.  Bradford,  Boston  Med.  and  Surg.  Journal,  Aug.  i6th,  1888. 
=  Best.  Med.  and  Surg.  Journal,  April  26th,  1S85,  392. 


////'  nisi'iASE.  355 

in  most  cases  is  impracticable  before  operation).  The  operation 
may  be  superficial  or  deep,  and  should  be  performed  with  every 
possible  antiseptic  precaution.  Superficial  punctures  may  be  made, 
or  the  cauterization  may  be  carried  to  the  hone,  i)X  the  compact 
tissue  of  the  epiphysis  may  be  trephined  and  the  spongy  tissue 
thoroughly  cauterized  with  the  Paquelin  point.  The  reporter 
claims  remarkable  success  from  the  treatment,  but  the  method  has 
not  been  received  with  much  favor. 

Amputation. — The  question  of  am[)utation  of  the  diseased  limb 
alone  remains  for  consideration. 

Neglected  cases  of  hip-joint  disease  occasionally  present  them- 
selves, in  which,  owing  to  extensive  caries  of  the  pelvis  or  in  the 
length  of  the  femur,  excision  offers  no  chance  for  a  cure;  in  other 
instances  excision  has  failed  to  arrest  the  destructive  process  in 
the  bone,  and  the  surgeon  is  left  to  choose  between  surrendering 
the  patient  to  a  lingering  and  wretched  death,  or  the  very  radical 
measure. of  amputation  at  the  hip-joint.  In  making  this  choice  he 
needs  information  as  to  the  chances  of  recovery  offered  by  amputa- 
tion, and  if  the  operation  is  decided  on,  as  to  the  best  method  of 
procedure.  The  former  cannot  be  found  in  the  ordinary  tables  of 
mortality  after  amputation,  as  it  would  appear  that  the  risk  of  death 
is  greater  when  this  operation  is  performed  after  injury,  or  for  the 
removal  of  tumors,  than  when  the  patient  is  freed  by  the  amputa- 
tion from  an  extensively  carious  and  useless  limb,  which  has  itself 
served  as  an  impediment  to  recovery. 

Ashhurst '  has  collected  thirty-four  cases  of  primary  amputation 
at  the  hip-joint  for  hip  disease,  and  thirty-one  consecutive  (that  is, 
after  excision),  and  found  nineteen  deaths.  This,  rejecting  five 
cases  where  the  result  was  undetermined,  would  give  a  mortality  of 
thirty-two  per  cent.- 

The  death-rate  of  amputation  at  the  hip-joint  after  injury  is  70.9 
per  cent,  and  for  disease  in  general,  42.6  per  cent. 

It  is  to  be  expected  that  this  percentage  of  mortality  may  be 
reduced  by  greater  attention  to  detail,  as  is  the  case  with  other 
large  operations.  In  fact,  an  examination  of  the  accompanying 
table  of  cases  of  hip  amputation  (after  hip  disease)  done  since 
Ashhurst's  table  was  made,  would  substantiate  this  idea.  This  is 
the  more  noticeable  as  important  improvements  in  controlling 
hemorrhage  have  lately  come  into  vogue  in  the  operation. 

'  "  International  Encyclopedia  of  Surgery,"  vol.  iv. ,  page  501. 

^  One  of  these  nineteen   fatal   cases   (that  of    Buffos)    should    strictly   be   considered 
an  operative  success,  as  death  did  not  take  place  till  three  months  after  the  operation. 


356 


OR  THOPEDIC  S  UR  GER  V. 


List  of  Amputations  at  the  Hip-Joint  for  Hip  Disease,  not  included 
IN  Ashhurst's  Tables. 


No. 

Surgeon. 

Result. 

Reference. 

I 
2 

3 

Beddard  ' 
Bradford 
F.  Jordan 

Recovered 
Died 

British  Medical  Journal,  June  7th,  1884,  p.  1,080. 
Boston  Med.  and  Surg.  Journal,  Dec.  nth,  1884,  p. 564. 
British  Medical  Journal,  loc.  cit. 

^11                      1 .                      11                         a 

4 

5 
6 

7 
8 

9 

lO 

Lediard 

Littlewood 

Lloyd 

Lutz 

Maclaren 

Recovered 

St.  Louis  Med.  and  Surg.  Journ.,  1879,  xxxvii.,  p.  560. 
British  Medical  Journal,  loc.  cit. 

12 

13 
14 
15 
i6 

17 

i8 

19 
20 
21 
22 

Marshall 

« 

British  Medical  Journal,  1885,  xliv.,  p.  220. 

May 
Pilcher 

Roddick 
Shuter 

Spofforth 

1  ( 

Died 
Recovered 

British  Medical  Journal,  June  7th,  1884,  p.  1,080. 

Philadelphia  Medical  News,  1885,  xlvi.,  p.  220. 
Clinical  Society  Transactions,  1882-83,  xvi. ,  p.  86. 
British  Medical  Journal,  1884,  p.  1,080. 

According  to  Ashhurst,  in  60  cases  there  were  19  deaths;  in  the 
table  of  later  cases,  22  cases,  with  3  deaths;  'making  a  total  of  82 
cases,  with  22  deaths;  giving  a  mortality  of  27  per  cent,  and  in  the 
22  cases  done  since  1880,  a  mortality  of  only  14  per  cent.  This 
table  does  not  include  other  successful  cases  reported  by  Denons, 
Buchanan  and  Wheaton,  as  it  was  not  certain  from  the  report 
that  the  hip-joint  was  involved  in  the  caries  or  necrosis.  The 
mutilation  which  results  is  the  chief  objection  to  the  operation, 
and  is  but  partially  met  by  an  artificial  limb.  An  undoubted  refor- 
mation of  bone  has  taken  place  in  the  case  operated  upon  by  the 
writer  three  years  ago.  As  yet  no  artificial  limb  has  been  fitted, 
as  the  patient  is  still  young — ten  years  of  age. 

Absoluie  economy  of  blood— of  the  utmost  importance  in  all  hip 
amputations— is  vital  in  cases  reduced  to  the  physical  extremity 
seen  in  cases  of  hip  disease  undergoing  this  operation. 

For  controlling  hemorrhage  neither  digital  compression  nor  ab- 
dominal tourniquets  are  to  be  trusted,  although  the  former  can  be 
used  in  children  with  less  risk  than  in  adults,  and  is  still  employed 
by  Marshall.  Davy's  lever  in  the  rectum  has  caused  death  by 
perforation  'of  the  gut,  and  has  little  but  novelty  in  its  favor.' 
Trendelenburg's  method  of  compressing  the  flaps  by  means  of  a 
rubber  tube  which  is  placed  over  the  thigh  and  is  wound  round 
both  ends  of  a  steel  rod  passed  through  the  thigh,  the  vessels  being 
1  Brit.  Med.  and  Surg.  Journal,  September  13th,  1885. 


////'   DfSI'.ASE.  357 

compressed  between  the  rod  and  tlic  i-ubl)cr  tube,  presents  no  ad- 
vantages over  an  elastic  cf)nii)ression  [properly  a[)plied.  The  best 
way  is  that  described  by  Mr.  Jordan  Lloyd." 

The  limb  should  be  elevated  and  strip))e(l  of  blood,  and  an  elas- 
tic bandage  is  doubled  and  passed  between  the  thighs,^  its  centre 
lying  between  the  tuber  ischii  of  the  side  to  be  operated  upon  and 
the  anus.  A  pad  in  the  shape  of  a  roller  bandage  is  tied  over  the 
external  iliac  artery,  the  ends  of  the  rubber  are  drawn  tightly 
upward  and  outward  (one  in  front  and  one  behind)  to  a  point  above 
the  centre  of  the  iliac  crest  of  the  same  side.  The  front  i)art  of 
the  band  passes  across  the  compress,  the  back  part  runs  across  the 
great  sciatic  notch  and  prevents  bleeding  from  the  branches  of  the 
internal  iliac.  The  ends  of  the  bandage  are  tightened,  and  should 
be  held  by  the  hand  of  an  assistant  placed  just  above  the  centre  of 
the  iliac  crest.  Mr.  Lloyd  suggests  that  a  short  piece  of  wooden 
rod  can  be  slipped  under  the  elastic,  and  is  a  convenience  in  hold- 
ing this  rubber  band;  the  elastic  bandage,  however,  should  not  be 
allowed  to  slip  down  below  the  iliac  crest  or  over  the  tuber  ischii. 
This  can  be  done  by  the  hand  of  an  assistant  or  by  passing  a  band- 
age under  the  elastic  and  tying  it  to  the  patient's  shoulder. 

The  method  of  disarticulating,  so  popular  in  the  operating  classes, 
and  known  as  Lisfranc's  method,  is  not  readily  done  if  an  elastic 
tourniquet  is  used.  To  check  all  bleeding,  it  will  be  found  most 
convenient  to  amputate  as  if  at  the  upper  part  of  the  thigh,  and  tie 
all  bleeding  points,  removing  the  remaining  fragment  by  a  lateral 
incision.  This  is  practically  the  method  recommended  by  INL 
Furnaux  Jordan.  A  lateral  incision  is  made  as  in  excision  of  the 
head  of  the  femur,  the  head  of  the  femur  is  excised  in  order  that  it 
may  be  out  of  the  way,  the  lateral  incision  is  prolonged  and  the  shaft 
of  the  femur  separated  for  two  or  three  inches  in  its  length  from 
the  surrounding  muscles,  takhig  care  that  the  periosteum  remain 
with  the  muscles.  A  circular  amputation  of  the  thigh  is  then  done, 
the  bone  sawn  through,  or  if  entirely  freed  from  the  surrounding 
tissues  by  the  lateral  incision,  pulled  out  from  the  flaps.  The  ves- 
sels are  tied  and  the  tourniquet  removed. 

The  operation  in  this  way  can  be  performed  without  the  loss  of 
any  appreciable  amount  of  blood,  and  there  is  time  for  due  delib- 
eration, as  there  is  no  danger  of  a  death  upon  the  table  by  a  sud- 
den gush  of  hemorrhage. 

^  Lancet,  May  26th,  1SS3. 

^  The  writer  has  used  large  rubber  tubing  in  preference  to  the  rubber  band  described 
by  Mr.  Lloyd.  If  pulled  tight  the  pad  is  not  necessary.  It  has  also  proved  convenient  to 
use  the  tubing  long  enough  that  the  ends  ma}-  be  brought  (after  the  tubing  is  fastened  on 
the  affected  side)  to  the  well  side  and  then  fastened. 


358  ORTHOPEDIC  SURGERY. 

The  following  conclusions  would  appear  to  be  justified :  amputa- 
tion at  the  hip-joint,  in  hip  disease,  should  be  regarded  as  the  very 
last  resort,  contra-indicated  by  extensive  amyloid  degeneration  of 
the  viscera,  or  a  moribund  condition  of  the  patient.  The  chances  of 
mortality  are  not  greater  than  those  in  amputation  of  the  thigh  in 
general,  and  the  chances  of  a  permanent  cure  (barring  the  mutila- 
tion) would  appear  to  be  greater  than  after  excision  at  the  hip- 
joint.  The  amputation  should  be  done  sub-periosteally  whenever 
it  is  possible.  An  elastic  tourniquet  gives  the  best  means  of  pre- 
venting hemorrhage.  Preliminary  excision  of  the  head  of  the 
femur,  in  fi^eeing  the  upper  part  of  the  shaft,  will  be  found  to 
facilitate  the  amputation. 

Summary. — It  is  difficult  to  summarize  the  treatment  of  hip  dis- 
ease, for  the  reason  that  cases  differ  greatly  in  severity ;  some  need- 
ing complete  fixation  with  recumbency  for  a  very  long  period, 
owing  to  an  amount  of  sensitiveness  or  to  the  activity  of  the  ostitis, 
while  in  other  cases  ambulatory  treatment  with  proper  appliances 
is  sufficient  without  recumbency. 

The  proper  treatment  of  hip  disease  is,  therefore,  not  the  exclu- 
sive use  of  any  splint  or  method  {i.e.,  of  rest  or  extension),  but  the 
use  of  such  means  as  may  meet  the  indications  as  they  are  present. 
During  the  acute  stages,  the  hip-joint  should  be  fixed  efficiently 
either  in  bed  or  in  some  fixative  appliance.  This  implies  rest  with 
fixation,  and  the  use  of  thorough  traction.  Continued  confinement 
to  bed  is  not  beneficial  for  the  general  condition  of  tuberculous 
patients,  except  temporarily  during  the  acute  stage  ;  and  as  soon 
as  the  acute  symptoms  have  subsided  the  patient  should  be  allowed 
to  go  about  with  the  hip  thoroughly  protected  against  jar  and 
spasm.  This  can  be  done  by  means  of  a  traction-splint,  if  effi- 
ciently applied. 

At  first,  until  patients  become  used  to  a  splint  (the  Davis-Taylor 
splint),  crutches  will  be  found  an  aid  in  locomotion.  If  the  acute 
symptoms  return  under  this  method,  thorough  fixation  and  rest  in 
bed  are  again  indicated.  If  the  subacute  symptoms  diminish  and 
there  is  less  muscular  rigidity  at  the  hip-joint,  greater  freedom  can 
be  allowed,  and  eventually  traction  discontinued,  and  the  joint 
merely  protected  from  jar.  This  should  be  continued  as  long  as 
there  is  any  danger  of  recurrence  of  active  symptoms,  or  tendency 
to  contraction. 

In  brief,  the  hip  should  be  fixed  as  long  as  it  is  sensitive,  should 
be  protected  and  traction  used  as  long  as  there  is  muscular  spasm, 
and  protected  as  long  as  it  is  weak.  The  best  results  are  only  at- 
tained by  great  care  for  a  year  or  two  at  least,  and  careful  super- 
vision and  protection  for  two  or  three  subsequent  years.     Distor- 


////'  JJ/SKASJC.  359 

tions  of  the  limb  should  always  be  prevented  as  they  occur  and  in 
many  cases  some  motion  can  be  saved  at  the  hip-joint,  if  protec- 
tion is  not  discontinued  too  soon.  Abscesses  can  be  treated  on 
general  surgical  principles.  Radical  operative  mea.sures  are  needed 
only  in  exceptional  cases  if  thorough  conservative  treatment  can 
be  secured. 


CHAPTER  VII. 

OTHER    DISEASES    OF   THE    HIP-JOINT. 

Chronic  Synovitis. — Symptoms. — Diagnosis. — Treatment. — Arthritis  Defor- 
mans.— Pathology  and  Etiology. — Symptoms.— Diagnosis. — Treatment. — 
Charcot's  Diseases  of  the  Hip-Joint. — The  Acute  Arthritis  of  Infants. — 
Syphilitic  Disease  of  the  Hip. — Periostitis  of  the  Hip. — Malignant  Disease 
of  the  Hip. — Loose  Cartilages  in  the  Hip-Joint. — Interstitial  Absorption 
of  the   Neck  of  the  Femur. 

Chronic  Synovitis. 

Symptoms. — Serous  synovitis  of  the  hip-joint  is  rarely  seen.  The 
existence  of  chronic  tubercular  synovitis  of  the  hip-joint  has 
been  questioned,  but  there  seems  to  be  no  reason  why  such  an 
affection  may  not  well  exist  and  escape  detection,  for  the  reason 
that  post-mortem  examinations  are  made  after  the  disease  has  ex- 
tended and  involved  the  whole  joint.  Chronic  synovitis  of  the 
hip-joint  not  extending  to  the  bone  is  an  uncommon  affection.  In 
a  majority  of  cases,  its  existence  must  be  an  inference  rather  than 
a  positive  diagnosis.  But  this  inference  may  be  made  with  good 
reason  in  a  certain  class  of  cases  where  the  symptoms  of  hip  disease 
(limp,  pain,  and  stiffness)  disappear  in  a  few  months  and  do  not  re- 
appear. 

The  present  state  of  our  knowledge  with  regard  to  these  affec- 
tions does  not  make  it  possible  to  differentiate  in  children  between 
a  synovitis  and  a  real  coxitis  in  the  early  acute  stage.  Only  when 
the  symptoms  have  subsided  with  a  rapidity  Avhich  is  impossible  in 
a  serious  bone  lesion,  is  the  surgeon  justified  in  making  the  diag- 
nosis of  synovitis.  That  such  synovitis  exists  at  times  has  been 
proven  in  the  case  quoted  above. 

The  course  of  acute,  subacute,  or  chronic  synovitis '  of  the  hip- 
joint  (if  limited  to  the  synovial  membrane  and  not  extending  to 
the  cartilage  or  bone)  is  not  as  protracted  as  that  of  epiphyseal 
ostitis. 

Synovitis  of  the  hip-joint  from  traumatism  may  occur  in  sprains 
and   contusions,    the  extent  and  course  of  such  synovitis  depend 

^  "  Coxitis  hsemorrhagica  " :  AUgem.  Med.  Central-Zeitung,  December  13th,  1871. 


orni'iR  DISEASES  ()/•'  Jill':  iiir  joint.  361 

upon  the  nature  and  amount  of  the  injury.  In  patients  with  tuber- 
cular predisposition,  such  injuries  may  produce  tubercular  disease. 
In  certain  cases,  a  synovitis  of  this  sort  passes  away  without  perma- 
nent injury;   in  other  cases,  permanent  disease  or  ankylosis  results. 

Diagnosis. — In  the  adult,  chronic  synovitis  might  be  diagnostic- 
ated after  a  severe  sprain  of  the  joint  where  the  symptoms  of  an 
acute  synovitis  had  clearly  been  present,  and  had  passed  on  to  the 
chronic  stage.  When  there  is  much  distention  of  the  capsule, 
swelling  may  be  found  in  the  groin  above  Poupart's  ligament  and 
behind  the  great  trochanter.  Flexion  of  the  thigh  is  generally 
present,  and  muscular  fixation  may  also  be  noted  holding  the  thigh 
in  that  position.     The  affection  is  not  common  even  in  adults. 

In  children  the  diagnosis  of  synovitis  of  the  hip-joint  should  only 
be  made  when  recovery  has  occurred  in  a  few  weeks  and  has 
proved  permanent. 

Treatment. — The  treatment  can  be  summed  up  in  a  very  few 
words.  Cases  of  chronic  synovitis  of  the  hip-joint  are  to  be  treated 
in  the  same  way  as  cases  of  tubercular  ostitis,  if  from  the  severity 
or  duration  it  may  be  supposed  that  there  is  danger  of  extension 
of  the  disease  to  the  cartilage  and  bone. 

Cases  in  adults  which  are  clearly  to  be  recognized  as  synovitis 
should  be  treated  by  rest  and  counter-irritation,  application  of  hot 
packing  or  of  ice  bags,  blisters,  etc.,  back  of  the  trochanter. 
And  every  care  should  be  taken  to  guard  against  using  the  unpro- 
tected limb  too  soon. 

Arthritis  Deformans. 

Arthritis  deformans  of  the  hip-joint  is  an  affection  which  is  not 
uncommon  in  patients  above  the  age  of  forty-five.  It  may  occur 
as  a  monarticular  affection  or  in  connection  with  a  simultaneous 
affection  of  some  of  the  other  joints. 

Pathology  and  Etiology. — When  affecting  the  hip  it  is  knoAvn  as 
senile  coxitis,  malum  coxae  senile,  chronic  rheumatoid  arthritis  of 
the  hip,  etc.  It  begins  in  many  cases. insidiously,  while  in  others, 
and  especially  monarticular  cases,  it  follows  after  a  fall  upon  the 
trochanter.  From  the  shortening  of  the  head  and  neck  in  these 
cases  it  has  been  supposed  by  some  writers  to  be  an  impacted  frac- 
ture of  the  neck  of  the  femur,  but  the  shortening  results  from  the 
absorption  of  the  head  and  is  in  every  way  like  the  pathological 
changes  found  in  the  insidious  cases. 

Mr.  Adams  divides  the  case  into  two  classes,  basing  the  distinc- 
tion on  the  pathological  appearance  of  a  large  number  of  specimens 


362  ORTHOPEDIC  SURGERY. 

examined.  Class  I.  comprises  those  cases  in  which  the  hypertro- 
phic changes  predominate.  This  consists  in  an  enlargement,  thick- 
ening, and  increase  in  density  of  the  head  of  the  femur. 

In  Class  II.,  the  atrophic  changes  predominate.  The  bone  is 
lighter  and  is  usually  light  and  porous,  or  spongy,  and  the  head 
and  neck  of  the  bone  are  diminished  in  size. 

There  are  other  cases  which  seem  to  hold  an  intermediate  posi- 
tion, and  in  which  both  the  hypertrophic  and  atrophic  changes 
are  combined. 

Symptoms. — The  affection  begins  with  pain  in  and  about  the 
joint  and  shooting  down  the  course  of  the  sciatic  nerve  at  the  back 
of  the  leg  instead  of  down  the  front  as  in  epiphyseal  ostitis.  At 
this  stage  the  affection  very  closely  simulates  sciatic  neuralgia. 
Movements  of  the  joint  beyond  a  certain  arc  are  painful,  and  a 
noticeable  limp  is  present.  Flexion  and  eversion  are  particularly 
painful  movements  to  the  patient,  and  if  the  leg  is  manipulated  a 
distinct  creaking  is  sometimes  felt  which  is  most  noticeable  when 
the  movements  are  most  painful. 

Muscular  atrophy  of  the  limb  comes  on  and  the  nates  of  the 
affected  side  are  flaccid  and  flattened,  and  apparent  shortening 
from  flexion  and  adduction  is  present  in  the  diseased  limb,  as  well  as 
true  bone  shortening  in  exceptional  cases,  reaching  even  two  inches 
or  more.  Muscular  fixation  is  at  first  not  a  prominent  symptom, 
except  in  very  sensitive  conditions  of  the  joint,  but  the  arc  of 
motion  gradually  diminishes  until  finally  the  joint  becomes  entirely 
stiff  in  perhaps  a  normal  position,  or  perhaps  adducted  or  flexed. 
In  the  earlier  stages  abduction  and  apparent  lengthening  of  the 
limb  may  be  present  as  in  hip  disease.. 

The  position  which  the  limb  assumes  in  the  more  advanced 
cases  of  the  disease  is  one  which  is  calculated  to  be  most  mislead- 
ing, especially  when  the  affection  has  followed  a  fall  upon  the 
trochanter.  The  limb  is  rotated  outward  and,  with  the  apparent 
shortening,  presents  almost  a  complete  picture  of  an  impacted  frac- 
ture of  the  neck  of  the  femur.  In  other  instances  the  thigh  may 
be  flexed  and  adducted  as  in  hip  disease  proper. 

Arthritis  deformans  of  the  hip-joint  does  not  show  any  tendency 
to  go  on  to  suppuration. 

Diagnosis. — The  affection  is  likely  to  be  confused  with  sciatica 
and  impacted  fracture  of  the  neck  of  the  femur. 

In  sciatica  the  limitation  of  motion  is  governed  by  the  amount 
of  pain  produced  by  the  movement  of  the  sensitive  parts  and  by 
the  tension  on  the  nerve,  and  therefore  differs  from  that  resulting 
from  true  hip-joint  disease.  Flexion  is  usually  free  to  a  certain 
limit,  but  impossible  beyond  this  and  if  the  leg  is  held  extended 


OTIIKR   DISl'lASI'S   01'     Till':   II II'  JOINT.  363 

on  the  thigh  this  is  particuhirly  noticeable.  In  sciatica,  hypcrex- 
tension  is  not  interfered  with  nor  rotation  nf)r  lateral  motion.  The 
diagnosis  from  true  hip  disease  is  based  chiefly  011  the  patient's  age; 
tubercular  epiphyseal  ostitis  being  (juitc  rare  in  adults  excej^t  in 
connection  with  weJI-marked  tubercular  disease. 

Treatment. — Morbus  coxae  senih's  or  arthritis  deformans  demands 
treatment,  first  to  relieve  the  pain  and  secondly  to  correct  the  de- 
formity. 

The  symptom  of  pain  is  rarely  so  great  as  to  cause  disability, 
unless  other  joints  are  affected.  In  such  cases  hot  baths,  m.assage, 
galvanism,  hot  packs,  and  the  administration  of  salicin,  colchicum, 
lithia,  and  potash  are  to  be  recommended  in  the  treatment  of 
chronic  rheumatism  of  the  hip  as  of  other  forms  of  chronic  rheu- 
matism. The  use  of  crutches  and  canes  will  often  be  needed.  The 
deformities  which  follow  this  affection  are  usually  those  seen  in  hip 
disease,  but  they  are  more  gradual  in  development.  They  are  per- 
sistent and  obstinate,  but  are  amenable  to  proper  mechanical  treat- 
ment, such  as  is  used  in  the  deformities  of  hip  disease. 

H.  L.  Taylor,  in  a  recent  article,'  has  related  several  cases  wdiere 
rest  to  the  joint  was  afforded  by  recumbency  and  traction  and 
afterward  the  joint  was  protected  for  a  long  time  by  a  simple  pro- 
tection apparatus  like  that  advocated  for  use  in  convalescent  hip 
disease.     The  results  were  favorable  in  the  extreme. 

More  is  to  be  gained  ordinarily  by  gradual  correction  by  me- 
chanical means  than  by  forcible  straightening  in  this  class  of  affec- 
tions of  the  hip. 

The  medicinal  and  dietetic  treatment  of  the  affection  will  be 
considered  in  speaking  of  arthritis  deformans  of  the  knee  in  Chap- 
ter IX. 

Charcot's  Disease  of  the  Hip-Joint. 

In  frequency  of  attack  the  hip  comes  next  to  the  knee,  which 
among  the  large  joints  is  the  one  most  frequently  attacked.  As 
in  most  other  instances,  Charcot's  disease  of  the  hip  simulates  ver}' 
closely  arthritis  deformans  of  the  ordinary  type.  The  changes  in  the 
joint  are,  however,  much  more  acute  and  extensive  than  those  with 
which  we  are  familiar  in  arthritis 'deformans.  Synovial  effusion  is  a 
more  prominent  symptom,  sometimes  reaching  the  stage  of  large 
fluctuating  tumor  which  presents  itself  at  the  front  and  the  back  of 
the  joint,  with  a  wearing  away  of  the  head  of  the  bone.  The  trochan- 
ter ascends  and  a  state  of  affairs  similar  to  the  condition  found  in 
late  hip  disease  is  presented.  In  the  matter  of  diagnosis,  of  course 
'  "  Senile  Coxitis,"   N.  Y.  Med.  Journal,  Dec.  15th,  1888. 


364  ORTHOPEDIC  SURGERY. 

one  depends  upon  the  co-existence  of  symptoms  of  spinal  cord 
disease.  As  to  treatment,  nothing  can  be  accomplished ;  in  cases 
where  swelling  is  excessive,  aspiration  of  the  joint  sac  may  give 
temporary  relief.  In  cases  where  syphilitic  history  is  present, 
mercury  or  iodide  of  potash  should  be  given,  and  in  certain  cases 
they  have  a  marked  influence  in  checking  the  disease.  Rest  is 
indicated  for  the  joint. 

The  acute  artJiritis  of  infants'"  may  at  times  affect  the  hip-joint. 
It  consists  of  an  acute  epiphysitis  which  attacks  children  less  than 
a  year  old.  The  disease  was  originally  described  b}/  Mr.  T.  Smith,  in 
St.  Bartholomew's  Hospital  Reports  (Vol.  X.).  Its  etiological  rela- 
tions are  very  obscure,  its  character  is  acute,  and  its  course  is  rapid. 
It  may  result  from  injury.  The  swelling  is  very  great  and  it  may 
appear  in  one  of  the  large  joints,  only  to  disappear  there  and  man- 
ifest itself  elsewhere.  The  treatment  should  consist  of  free  incision 
and  stimulation  of  the  patient,  for  the  outlook  is  very  grave  on  ac- 
count of  a  tendency  to  pyaemia  and  also  because  of  the  severe 
character  of  the  affection. 

Syphilitic  disease  of  the  hip  may  occur  at  times.  It  occurs  most 
often  as  a  subacute  synovitis  as  in  the  other  joints  during  the 
secondary  stage.  Rarely  it  is  present  as  a  gummatous  infiltration 
of  the  head  and  neck  of  the  femur. 

Hip  disease  of  the  ordinary  type,  as  pointed  out  by  Mr.  Wright, 
may  occur  in  the  subjects  of  tertiary  syphilis,  and  run  a  typical 
course  apparently  unaffected  by  the  syphilitic  element  present. 

Periostitis  of  the  Hip. — Gibney  calls  attention  to  the  little  notice 
which  has  been  accorded  to  this  affection,  which  is  at  times  well 
marked.  It  occurs  mostly  about  the  trochanter,  as  the  result  of 
traumatism,  and  it  follows  soon  after  the  injury.  It  tends  to  run  a 
chronic  course,  and  localized  tenderness  without  implication  of 
joint  motion  may  be  present  for  months. 

In  short  it  may  be  said  that  simple  periostitis  about  the  hip-joint 
may  result  from  injury,  but  periostitis  is  so  common  an  accompa- 
niment of  tuberculous  ostitis  that  the  diagnosis  should  be  made 
with  very  great  care. 

The  treatment  consists  in  the  avoidance  of  motions  which  cause 
pain,  and  the  application  of  blisters. 

The  occurrence  of  deep  sensftiveness  and  pain  about  the  hip 
after  an  injury  may  be  due  to  periostitis,  a  muscular  or  ligamentous 
strain,  simple  synovitis,  or  chronic  articular  ostitis,  and  in  the  pre- 
ceding pages  an  effort  has  been  made  to  show  the  difficulty  of  the 
accurate  differentiation  of  these  conditions. 

'  The  subject  is  treated  at  length  in  a  recent  article  by  Dr.  W.  R.  Townsend,  Am. 
Journ.  Med.  Sci.,  Jan.,  1890. 


OTHER  DISEASES  OF    THE  I///'  JOINT.  365 

Malignant  disease  of  the  hip  is  a  rare  affection  which  has  not 
received  much  attention.  In  speaking  of  it  Gibney  says  with  much 
truth:  "Its  beginning  is  obscure,  its  termination  is  fatal,  and  its 
early  recognition  next  to  impossible." 

The  variety  of  tumor  which  most  often  affects  the  head  of  the 
femur  in  young  children  is  a  round-cell  sarcoma  of  the  periosteum. 
But  the  epiphysis  is  rarely  the  seat  of  the  tumor.  In  seventy  cases 
of  sarcoma  of  the  femur,  analyzed  by  Gross,  there  were  only  two 
cases  where  the  upper  epiphysis  was  affected.' 

The  early  symptoms  in  cases  where  the  head  of  the  femur  is  not 
primarily  involved  are  very  slight  and  consist  chiefly  of  a  swelling 
which  is  painless  and  not  fluctuating ;  limp,  and  slight  restriction 
of  motion,  may  be  present.  Soon,  however,  it  becomes  evident  that 
the  enlargement  is  predominating  over  all  the  other  symptoms  and 
the  swelling  progressively  increases,  suggesting  perhaps  hip  abscess. 
Fluctuation,  however,  is  absent  and  the  swelling  embraces  the 
whole  circumference  of  the  limb.  There  is  an  enlargement  of  the 
superficial  vessels  and  the  swelling  later  becomes  enormous.  The 
child  becomes  emaciated  and  wastes  away.  The  affection  may  be 
very  painful  or  again  it  may  be  attended  with  very  little  suffering. 
Treatment  is  of  course  hopeless. 

Loose  cartilages  in  the  hip- joint  are  so  exceptional  as  to  be  sim- 
ply anatomical  curiosities.  The  symptoms  are  similar  to  those 
described  under  the  head  of  loose  bodies  in  the  knee-joint.  Their 
removal  by  operation  is  not  feasible. 

HemorrJiagic  synovitis  of  the  hip-joint  has  been  reported  as  one 
of  the  curiosities  of  surgery. 

Wright  describes  a  condition  which  he  classes  as  interstitial 
absorption  of  the  neck  of  the  feninr.  Bell,  Liston,  and  Gulliver 
and  Monks-  have  described  it  as  a  pathological  condition  which  is 
occasionally  found  in  the  hips  of  young  people  after  a  fall  on  the 
trochanter.  The  patient  becomes  lame  and  complains  of  a  slight 
amount  of  pain.  Motion  is  free  at  the  joint  and  a  certain  amount 
of  pain  is  present.  A  flattening  of  the  head  of  the  femur  is  found 
in  these  cases,  which  accounts  for  the  shortening  of  the  limb.  Oc- 
casionally it  disappears  after  a  time,  while  again  it  infects  the  joint 
secondarily.  It  is  of  course  questionable  whether  it  should  find  a 
place  as  a  separate  affection,  for  what  is  said  of  it  suggests  to  one's 
mind  the  occurrence  of  a  focus  of  disease  away  from  the  joint  sur- 
face which  may  either  disappear  or  break  into  the  joint — a  condi- 
tion which  has  been  fully  treated  in  the  Pathology. 

'  Am.  Journ.  Med.  Sci.,  Jul}'  and  Oct.,  1879. 

=  Boston  Med.  and  Surg.  Journal,  Nov.  iSth,  18S6. 


CHAPTER   VIII. 

TUMOR  ALBUS  OF  THE  KNEE-JOINT. 

Definition.— Pathology. — Clinical       History. — Diagnosis. — Differential    Diag- 
nosis.— Prognosis. — Treatment,  {a)  Conservative,  (J?)  Operative  (Excision. — 
■     Arthrectomy. — Amputation). 

Twnor  Albiis. — The  old  term  tumor  albus  is  here  applied  to  the 
most  common  of  all  knee-joint  affections,  otherwise  known  as  fun- 
gous disease  of  the  knee-joint,  etc.  The  term  tumor  albus  was 
chosen  for  use  in  this  connection,  because  it  involves  no  etiological 
or  pathological  theory  and  because  its  application  to  this  condition 
is  sanctioned  by  general  usage. 

The  affection  is  also  known  as  white  swelling,  strumous  arthritis, 
scrofulous  disease  of  the  knee,  chronic  purulent  or  fungous  synovitis 
of  the  knee,  and  by  all  the  other  terms  applicable  to  the  last-named 
affection,  as  noted  in  Chapter  IV. 

In  speaking  of  diseases  of  the  knee,  it  should  be  noted  that  this 
joint  is  the  largest  and  most  exposed  joint  in  the  body,  and  the 
one  most  fequently  attacked,  if  we  may  consider  Schiiller's  figures 
(referred  to  above)  as  representative. 

Anatomically,  it  should  be  noted  that  the  joint  surfaces  forming 
it  are  nearly  flat,  and  the  facets  in  the  tibia  shallow.  Owing  to  this 
fact,  the  tibia  is  easily  drawn  backward  and  flexed  by  the  ham- 
string muscles,  the  flexors  of  the  leg  being  much  stronger  than  the 
extensors,'  at  the  same  time  it  is  rotated  outward,  the  combination 
constituting  the  common  and  troublesome  deformity  which  is  the 
characteristic  one  after  tumor  albus. 

Pathology. 

Tumor  albus,  as  it  is  seen  in  children,  begins  oftenest  as  an  epi- 
physeal ostitis  of  the  tuberculous  type.  It  may  be  either  a  diffuse 
ostitis  or  limited  to  certain  portions  of  the  epiphysis,  and  the 
femoral  or  tibial  epiphyses  are  attacked  with  equal  frequency.  In 
rare  instances  the  patella  has  been  primarily  attacked.     But  it  be- 

'  Liiche :    Deutsch.     Z.    f.    Chir. ,  March   gth,   1885;    Sonnenburg :   Deutsch.    Z.    f.. 
Chir. ,  vii.,  p.  485  ;    Fischer:    Deutsch.  Z.  f.  Chir.,  viii.,  1-37. 


TC/MOh'   ylLnUS   OF    Till':   h-NFF.-jo/NT.  367 

crins  as  a  synovitis  oftcncr  than  hip  disease  does,  and  in  children  it 
Ts  not  uncommon  to  sec  an  effusion  gradually  absorb,  Icavmg  an 
infiltrated  and  thickened  synovial  sac,  and  a  condition  of  fungous 
degeneration  of  the  synovial  membrane  ensues  which  ends  by  at- 
tacking the  bone.  In  the  greater  number  of  cases,  however,  the 
bone  symptoms  clearly  precede  the  effusion. 


.    -      \ 


V      ^ 


\ 


Fig.  33i.-Appearance  of  the  Bones  of  the  Knee-joint  in  Tumor  Albus. 

The  origin  of  tumor  albus  is  in  the  bone,  in  the  majority  of  cases 
in  childreh;  in  adults  the  greater  proportion  of  cases  begin  in  the 
synovial  membrane,  with,  however,  even  there  a  certain  proportion 
of  primary  osseous  disease.  In  71  cases  of  tuberculous  jomt  dis- 
ease, Konig  found  47  of  bony  origin.  They  were  distributed  as 
follows : 


368 


ORTHOPEDIC  SURGERY. 

Osseous         Synovial. 


Hip,  . 
Knee,  . 
Foot,   . 

Shoulder, 
Elbow, 


8 

17 
II 

3 


The  pathological  appearances  of  tuberculous  joints  have  been  so 
fully  described  in  speaking  of  the  pathology  of  chronic  purulent 
synovitis  and  epiphyseal  ostitis  that  it  is  not  worth  while  to  enter 
upon  them  here  to  any  extent. 

Owing  to  the  large  size  of  the  articular  ends  of  the  bones  which 
enter  into  the  formation  of  this  joint,  it  is  not  uncommon  to  find 
sequestra  of  considerable  size  in  the  bony  ends,  which  are  ordina- 
rily in  the  form  of  a  wedge  with  the  base  toward  the  joint.  They 
are  not,  however,  the  accompaniment  of  early  tumor  albus. 

Whether  the  disease  begins  in  the  bone  or  the  synovial  mem- 
brane, the  ultimate  result  in  the  joint  is  likely  to  be  the  same.  In 
either  event  a  destructive,  fungous,  purulent  synovitis  generally 
develops,  which  becomes  the  characteristic  feature  of  the  process. 
This  may  end  in  a  complete  destruction  of  the  joint  or  in  arrest  and 
cicatricial  recovery. 


Clinical  History. 

It  is  not  in  general  necessary  or  expedient  to  distinguish  clinic- 
ally between  tumor  albus  of  bony  or  synovial  origin,  although  this 
can  occasionally  be  done  in  practice.  The  outcome  of  the  two 
varieties  is  practically  the  same  and  the  treatment  of  the  two  is 
similar.  It  may  be  said  that,  in  general,  the  affection  is  an  epiphy- 
seal ostitis.  The  affection  begins,  as  a  rule,  insidiously,  with  stiff- 
ness and  limp  in  gait.  The  disease  may  be  limited  for  a  long  time, 
and  be  manifested  by  an  enlargement  of  the  condyles  or  head  of  the 
tibia,  or  it  may  extend  and  involve  the  whole  joint;  occasioning 
severe  pain,  swelling  of  the  periarticular  tissues,  effusion  in  the 
joint,  periarticular  abscess,  and  distortion  of  the  limb,  i.e.,  flexion 
and  subluxation  ;  and  ending  in  a  natural  cure  with  fibrous  or  bony 
ankylosis  and  a  distorted  limb,  which  may  be  more  or  less  service- 
able, according  to  the  distortion ;  or  the  affection  may  result  in  so 
extensive  suppuration  as  to  endanger  life  from  septic  or  amyloid 
changes.  Sometimes  an  attack  of  severe  pains  supervenes,  and  an 
acute  stage  is  reached,  when  the  limb  is  flexed  at  the  knee,  hot  and 
tender  to  the  touch,  and  sensitive  to  any  jar.  This  stage  gradually 
subsides,  and  there  is  left  impairment  of  motion,  if  not  complete 


TUMOR  ALinis  ()/''  TJii-:  k'N /■:/■:- /o/jVT.  369 

stiffness.     Enlnrgcmcnt   of   the   bone   is   cliaracteristic   of   chrf;nic 
epiphysitis  of  the  knee,  if  it  persists  for  any  length  of  time. 

The  swelHng  at  the  knee,  unless  suppurative  synovitis  is  present 
to  a  marked  degree,  difTers  from  that  of  synovitis  with  effusion,  in 
that  the  swelling  is  of  the  bone  and  soft  peri-articular  tissues,  and 
is  not  altogether  within  the  joint.  If  tlie  effusion  is  large,  as  in 
chronic  serous  synovitis,  the  patella,  when  the  muscles  holding  it 
are  relaxed,  can  be  depressed  by  pressing  on  it,  and  be  felt  to  hit 
against  the  bone  as  it  floats  above  the  fluid  within  the  joint.  In 
effusion  the  shape  of  the  swelling  is  characteristic.  When  effusion 
is  the  characteristic  feature,  it  is  most  prominent  on  both  sides  of 
the  patella,  and  is  limited  by  the  tendon  of  the  quadriceps  ex- 
tensor muscle  and  by  the  ligamentum  patellae. 

In  these  cases  where  the  affection  begins  as  synovitis,  thickening 
of  the  joint  capsule  and  long-continued  synovial  fulness  are  the 
first  signs,  with  an  increasing  tenderness  over  the  joint  and  gradual 
limitation  of  its  motion.  Bone  enlargement  comes  on  and  the  con- 
dition is  soon  the  same  as  when  the  affection  began  in  the  more 
usual  way,  in  the  bone. 

In  tumor  albus  the  chief  symptoms  are  heat,  swelling,  tender- 
ness, and  joint  distention  ;  while  in  hip  disease,  a  different  class  of 
symptoms,  restriction  of  motion,  limp,  and  distortions  of  the  limb 
are  more  to  be  depended  upon. 

In  tumor  albus  of  bony  origin  the  knee  will  be  seen  to  have  lost 
its  definite  contour,  the  depressions  on  the  sides  of  the  patella  have 
become  filled  out  so  that  there  is  an  indistinctness  of  outline  w^hich 
is  as  perceptible  to  the  touch  as  to  the  sight.  There  is  no  floating 
of  the  patella,  unless  effusion  has  filled  the  joint,  but  the  patella 
seems  to  be  raised  from  its  position  by  a  semi-solid  mass,  the  whole 
knee  seems  surrounded  by  a  boggy  infiltration.  Later  it  assumes 
a  spindle  shape  and  the  distention  causes  the  skin  to  be  somewhat 
anaemic  in  the  more  severe  cases,  whence  the  name  of  tumor  albus. 

In  some  instances,  one  of  the  condyles — usually  the  internal  con- 
dyle— is  enlarged  more  than  the  other,  causing  knock-knee. 

In  the  milder  cases,  arrest  of  the  disease  may  occur  at  any  time 
with  more  or  less  complete  restoration  of  the  joint.  In  the  severer 
cases,  suppuration  may  follow,  with  the  establishment  of  sinuses. 
The  disease  progresses  to  cure  with  a  stiffened  limb,  or  the  destruc- 
tive process  may  become  so  extensive  that  excision  or  amputation 
is  required.  Like  all  these  diseases  the  course  of  the  affection  is 
favorably  affected  by  proper  treatment. 

Atrophy  of  the  muscles,  both  of  the  thigh  and   calf,  is  present, 
and   reaches  a  serious  degree  in  acute  cases.     It  is  quite  equally 
distributed  between  the  muscles  of  the  thigh  and  those  of  the  leg. 
24 


6/' 


ORTHOPEDIC  SURGERY. 


SJwrtening  is  a  much  less  important  factor  than  in  hip  disease, 
and  until  la-te  in  the  affection  does  not  appear  to  any  extent,  and 
this  late  shortening  comes  as  a  result  of  the  faster  growth  of  the 
well  leg,  oftener  than  as  the  outcome  of  bone  destruction.  During 
the  course  of  the  disease,  lengtJiening  of  the  affected  leg  may  occur. 
The  hyperaemia  occasioned  by  the  inflammation  induces  the  over- 
growth in  all  directions  of  the  tibial  and  femoral  epiphyses,  so  that 
they  outstrip  for  a  while  those  of  the  other  leg.  In  measuring  a 
child  with  tumor  albus  it  is,  therefore,  not  uncommon  to  find  the 
diseased  leg  half  an  inch  longer  than  the  other.  Later  in  the  dis- 
ease, the  trophic  disturbance  which  occurs  in  all  these  tuberculous 
joint  affections  makes  itself  felt  and  the  diseased 
leg  falls  behind  the  well  one  in  its  growth. 

Pain. — -The  pain  of  the  affection  is,  except 
during  the  acute  exacerbations,  not  severe, 
though  pain  on  jarring  the  limb  is  common. 
Night  cries  are  much  less  common  than  in  hip 
disease,  but  they  occur.  When,  however,  the 
patient  does  suffer  from  an  acute  exacerbation, 
the  pain  and  tenderness  are  excessive.  From 
the  exposed  condition  of  the  joint,  jars  and 
twists  are  very  common,  and  the  suffering  is  ex- 
treme. Tenderness  is  very  common,  especially 
over  the  inner  surface  of  the  head  of  the  tibia. 
In  certain  cases,  however,  the  knee  is  held  rigid 
by  muscular  spasm,  and  any  reasonable  manipu- 
lation fails  to  occasion  any  pain. 

Heat  of  the  affected  joint  is  present  and  is  a 
most  valuable  index  of  the  progress  of  a  case. 
Fig.  332.— Flexion  of  the    j^  ^^^  \^q   easily  felt  with  the  hand  as  long  as 

Knee-joint  in  Acute  Tumor  .  .  ,  .        , 

Albus.  the    disease    is    active,    but   when    it    becomes 

quiescent,  it  disappears,  to  return  at  once  if  anything  goes  wrong. 
It  can  be  felt  to  diminish,  if  treatment  is  successful  in  quieting 
the  condition  of  the  joint,  and  is  a  most  urgent  indication  for  pro- 
tective treatment  so  long  as  it  exists  in  any  degree. 

Lameness  is  a  constant  symptom.  It  varies  with  the  sensitive- 
ness of  the  joint  and  is  much  influenced  by  the  amount  of  flicxion 
present  in  the  diseased  knee. 

Muscular  fixation  is  a  symptom  of  this  as  of  all  chronic  tubercu- 
lar ostitis.  The  joint  may  be  held  perfectly  rigid  in  full  extension 
or  in  partial  flexion,  or  a  certain  arc  of  motion  may  be  permitted 
and  then  the  muscles  quickly  catch  the  joint  and  prevent  it  from 
going  further.  Persistent  muscular  spasm  results  in  the  character- 
istic malpositions  of  the  affection,  flexion,  and  subluxation  of  the 


TUMOR   A  Lin  J  S   ()/'■    Tin-:   KNFJ'l-JO/NT. 


37^ 


tibia.  Fixation  of  the  joint  by  niiisciil.ir  spasm  is  an  early  syinjj- 
tom,  perhaps  the  earliest  of  all,  in  tumor  albus  of  osseous  f>ri^in. 
When  the  disease  orig-inates  in  the  synovial  membrane,  on  the  other 
hand,  it  may  be  absent  until  a  comparatively  late  sta^^e  of  the  dis- 
ease. 

Alalpositions  of  the  limb  result  from  the  greater  power  which  the 
flexor  muscles  of  the  thigh  possess  than  the  extensors.  The  limb 
becomes  gradually  flexed  ahnost  from  the  first,  and  if  the  afi"ectif;n 

goes  on  without  treatment,  flex- 
ion may  reach  a  right  angle,  and 
this  is  the  almost  uncontrollable 
tendency  of  the  disease  and  the 
chief  obstacle  to  its  successful 
treatment. 


Fig.  333. — Subluxation  in  Knee-joint  Diseasa 
(Schreiber.) 


Fig.  334.— Subluxation  of  Knee.     Cross  Section. 
(Schreiber.) 


Even  when  the  affection  is  nearly  cured,  the  slightest  impru- 
dence on  the  part  of  the  patient  is  likely  to  bring  back  the  flexion, 
which  is  accompanied  by  increased  heat  and  tenderness.  Together 
with  the  flexion  and  as  a  result  also  of  the  predominance  of  the 
flexor  muscles  of  the  thigh,  subluxation  of  the  tibia  backward  oc- 
curs; this  is  due  to  the  shape  of  the  joint  surfaces,  and  the  persist- 
ent contraction  of  the  hamstring  muscles  alwa\'S  pulling  the  tibia 
backward.  If  the  leg  has  assumed  this  distortion  and  is  straight- 
ened, the  tibia  will  lie  in  a  plane  back  of  that  of  the  femur,  and  the 


372 


ORTHOPEDIC  SURGERY. 


part  of  the  knee  formed  by  the  femur  and  patella  will  be  unduly 
prominent. 

Another  result  of  long-continued  muscular  spasm  is  the  external 
rotation  of  the  tibia  upon  the  femur,  which  accompanies  severe 
grades  of  flexion  and  persists  after  straightening  of  the  leg  if  such 
is  accomplished.     In  the  same  way  a  certain  amount  of    knock- 


FiG.  335. — Subluxation  of  the  Tibia  in  Tumor 
Albus,  with  Tendency  to  Knock-knee. 


Fig.  336. — Flexion  of  the  Knee  and 
External  Rotation  of  the  Tibia. 


knee  is  apt  to  be  present  in  the  corrected  limb  after  severe  grades 
of  tumor  albus. 

Abscess  appears  either  as  a  purulent  distention  of  the  capsule, 
which  may  point  at  any  part  of  the  surface  and  discharge  by 
sinuses  for  an  indefinite  time,  or  abscesses  form  in  the  peri- 
articular tissues  as  in  hip  disease.  As  a  rule  abscess  formation  is 
accompanied  by  a  very  acute  degree  of  the  affection. 


Diagnosis. 

The  diagnostic  symptoms  and  signs  in  tumor  albus  are  an  inter- 
mittent lameness;  a  general  enlargement  of  the  knee-joint,  with  a 
feeling  of  stiffness  and  pain  on  using  the  limb;  he:.t  over  the  joint; 
and  the  presence  of  local  tenderness  and  muscular  stiffness  in  man- 
ipulation of  the  joint. 

The  character  of  the  enlargement  of  the  knee-joint  is  of  great 


rUMOR   ALB  us    UJ'     TJIJi   h'N  I'J'l-Jt)!  NT.  373 

importance.  If  it  is  in  the  form  of  a  synovial  distention,  the 
affection  is  perhaps  of  primary  synovial  orij^in,  and  must  be 
classed  as  synovitis.  If,  however,  there  is  no  fluctuatif^n  in  the 
joint,  it  is  clear  that  the  lesion  is  in  the  bone,  and  enlargement  of 
the  ends  of  the  bones  in  either  event  shows  the  same  condition  to 
be  present.  Bone  tenderness  over  the  head  of  the  tibia  increases 
this  probability,  and  the  limitation  of  motion  is  pathognomonic 
of  serious  disease,  when  joined  to  the  group  of  sympto.ns  above 
mentioned.  • 

Differential  Diagnosis. 

Synovitis. — Gross  errors  in  diagnosis  in  affections  of  the  knee  are 
not  common,  as  a  thorough  examination  of  the  joint  is  readily 
made.  The  distinction  between  a  synovitis  with  effusion  and  a 
chronic  ostitis  is  based  on  the  size  and  shape  of  the  swelling.  A 
diagnosis  between  a  subacute  synovitis  without  effusion  and  an 
epiphyseal  ostitis,  at  an  early  stage,  is  difficult  or  impossible. 

Practically  it  is  very  often  extremely  hard  to  differentiate  simple 
synovitis  from  a  beginning  tumor  albus,  indeed  it  is  in  many  cases 
impossible  to  do.  Sluggish  cases  of  synovitis,  especially  in  young 
or  feeble  persons  should  be  regarded  with  very  great  suspicion, 
inasmuch  as  they  are  likely  to  eventuate  in  tumor  albus  at  any 
time,  and  perhaps  the  condition  is  already  that  of  chronic  fungous 
synovitis. 

Peri-artiailar  Disease. — Peri-articular  disease  (inflammation  of 
bursae,  and  periarticular  abscesses)  is  to  be  distinguished  from  true 
articular  disease  in  that  there  is  little  or  no  joint  stiffness,  and  that 
the  swelling,  if  present,  does  not  bear  the  relation  to  the  patella 
that  occurs  when  there  is  fluid  beneath  the  patella  ;  the  distention 
being  clearly  outside  of  the  joint  sac. 

Functional  disease  (hysterical,  neuromimetic)  of  the  knee  is  to 
be  recognized  by  the  absence  of  objective  symptoms,  and  the 
prominence  of  subjective  symptoms.  Heat  is  absent,  limitation  of 
motion  and  tenderness  may  be  excessive,  and  swelling  and  alter- 
ation of  the  joint  contour  are  absent. 

ArtJiritis  defoi'vians  of  the  knee  occurs  as  a  spindle-shaped  en- 
largement of  the  bones,  with  but  little  tenderness  and  a  perceptible 
thickening  of  the  synovial  sac  with  infiltration  of  the  periarticular 
tissues.  Motion  is  more  or  less  lost  by  structural  changes,  but 
there  is  no  muscular  spasm.  A  very  characteristic  sign  is  a  pecu- 
liar creaking  which  is  felt  with  the  hand  on  the  joint  while  it  is 
beine  moved. 


374 


ORTHOPEDIC  SURGERY. 


Prognosis. 


The  prognosis  of  tumor  albus  is  similar  to  that  of  the  same  affec- 
tions of  the  other  large  joints.  Arrest  and  cure  may  be  anticipated 
in  the  early  and  lighter  cases,  even  if  not  thoroughly  treated,  but 
in  well-advanced  cases  some  disability  necessarily  follows,  and  in 
neglected  cases,  deformity  of  the  limb,  flexion  at  the  knee,  sublux- 
ation of  the  tibia,  and  the  formation  and  discharge  of  abscesses  are 
likely  to  occur,  ending  either  in  a  complete  destruction  of  the  joint 
or  in  a  cure  with  ankylosis.  A  liability  of  the  dissemination  of  the 
tubercular  disease  to  the  brain  or  lungs  exists  in  this  as  in  other 
similar  affections. 

The  functional  results  after  conservative  treatment  are  often  ex- 
cellent ;  sometimes  perfect  motion  is  restored,  but  in  general  only 
an  incomplete  arc  remains  with  occasionally  complete  rigidity. 
The  earlier  that  treatment  is  begun,  and  the  more  faithfully  it  is 
carried  out,  the  better  is  the  outlook  as  to  functional  results. 

In  all  severe  cases  there  is  a  danger  of  permanent  distortion  of 
the  limb.  This  may  be  so  severe  as  to  render  the  limb  useless. 
Flexion  of  the  limb  is  a  constant  result  in  severe  cases  unless 
treated  with  great  care. 

As  in  all  cases  of  epiphyseal  ostitis  of  the  larger  joint,  the  prog- 
nosis as  to  the  time  of  requisite  treatment  depends  not  only  on  the 
time  needed  to  check  the  inflammation,  but  also  for  the  re-estab- 
lishment of  sound  bone  tissue  capable  of  bearing  weight  without 
danger  of  relapse.  This  in  growing  children  demands  a  long  time. 
Protection  is  generally  necessary  from  one  to  two  years,  and  per- 
haps even  longer. 

Treatment. 

The  treatment  requires  the  greatest  care  to  preserve  the  func- 
tion of  the  joint  as  far  as  is  possible,  to  arrest  the  progress  of  the 
disease,  and  to  prevent  and  correct  deformities.  Aspiration  of  the 
joint,  incision,  injection  into  the  joint,  and  counter-irritation,  may 
be  all  indicated,  and  in  the  severe  cases  excision  or  arthrotomy. 

Conservative  Treatment  of  Twnor  Albus. — What  was  said  in  regard 
to  the  treatment  of  hip  disease  may  be  repeated  in  speaking  of 
epiphysitis  of  the  knee-joint.  The  treatment  should  be  thorough 
and  persistent,  and  should  meet  the  indications,  and  fixation  and 
protection  are  the  most  important  indications  in  diseases  of  the 
knee,  while  traction  is  less  so.  The  employment  of  protection 
should  be  continued  until  it  is  probable  that  the  epiphysis  is  nor- 
mal, which    is    a  matter   of   judgment  in  every  case.     Protection 


TUMOR   AIJU/S    ()/••    7 7/ A"    KN ICI-l-JOI NT.  375 

should  be  discontinued  gradually  and  tentatively;  if  discontinued 
too  soon,  recurrence  will  take  place,  or  the  deformity  of  the  limb 
will  increase.  Fixation  should  be  usetl  so  lon<(  as  there  is  any 
activity  of  the  inflammation;  this  is  indicated  by  pain,  muscular 
spasm,  or  tenderness.  Efficient  fixation  of  the  knee  does  not  re- 
quire confinement  to  bed. 

Fixation. — ^It  is  manifest  that  the  most  thorough  fixation  is  made 
if  the  fixing  appliance  is  as  long  and  extends  as  high  as  possible. 
The  leg  and  femur,  if  much  longer  than  the  appliance,  will  have  a 
greater  mechanical  advantage  than  if  the  splints  are  sufficiently 
long.  It  should  also  be  borne  in  mind  that  owing  to  the  fact  that 
the  thigh  is  well  covered  by  soft  tissues  a  certain  amount  of 
motion  is  possible  owing  to  the  yielding  of  the  soft  parts. 

Fixation  by  stifT  bandages  is  an  efTficient  method  of  treatment 
when  the  bandages  are  properly  applied.  They  should  reach  from 
the  groin  to  the  ankle,  and  as  firmly  as  possible  grasp  the  muscles 
of  the  limb.  Plaster  of  Paris  splints  are  made  by  the  application 
of  crinoline-gauze  bandages  impregnated  with  finely  divided  plaster. 
The  limb  is  first  wound  in  sheet  wadding,  and  then  the  plaster 
rollers  are  applied.  The  method  does  not  give  in  all  cases  certain, 
definite  support.  Dr.  Judson  says  in  regard  to  it:  "  It  may  be  an 
exaggeration,  but  it  conveys  the  idea,  to  say  that  a  plaster  of  Paris 
or  silicate  splint,  applied  to  the  leg  and  thigh,  contains  a  mass  of 
jelly  in  which  the  femur  is  but  little  restrained  from  motion,"  and 
in  a  degree  this  is  true  of  all  stiff  bandages. 

.  The  figure  (337)  shows  the  inefficiency  of  a  loosely  applied  plaster 
bandage  as  far  as  fixation  is  concerned.  Other  stiff  bandages  are 
of  silicate  of  potash,  which  may  be  cut  down  the  front  and  laced 
so  as  to  be  removed  at  any  time.  Leather  moulded  to  the  limb, 
and  stiffened  with  steel,  poroplastic  felt,  etc.,  are  all  convenient 
fixation  splints.  Fixation  without  protection  is  inadequate  treat- 
ment when  locomotion  is  desired.  For  this  reason  it  is  insufficient 
to  apply  a  plaster  splint  or  a  bone  splint  to  the  affected  leg  and  to 
allow  the  patient  to  walk  without  further  protection  of  the  limb. 

Fixation  as  a  means  of  treatment  so  far  has  only  been  considered 
as  applicable  to  the  limb  in  its  straight  position.  Much  more  often 
a  degree  of  flexion  is  present  to  complicate  matters,  the  treatment 
of  which  will  be  considered  later. 

Protection. — Protection  can  be  furnished  by  means  of  crutches, 
and  raising  the  sound  limb  by  a  thick  sole  which  alloAvs  the  affected 
limb  to  swing  clear  of  the  ground.  Better  protection  is  furnished 
by  means  of  a  splint  with  perineal  support  and  longer  than  the 
limb,  which  passes  under  the  foot  so  as  to  take  the  jar  of  locomo- 
tion.    The  best  of  these  splints  is  one  similar  to  that  already  de- 


1>7^ 


ORTHOPEDIC  SURGERY. 


scribed  as  a  protective  splint  in  hip  disease.     It  will  be  described 
more  fully  in  speaking  of  the  treatment  of  flexion  in  tumor  albus. 

A  simpler  appliance  is  the  Thomas  knee  splint,  which  consists  of 
a  padded  iron  ring  fitted  so  as  to  surround  the  thigh  at  the  peri- 
neum, and  fastened  to  two  rods  on  each  side  of  the  limb,  longer 
than  the  limb  and  secured  at  the  bottom 
to  a  metal  plate  below  the  foot  (Fig.  338). 

The  thigh  ring  is  placed  at  an  angle  of     \\     ""^^^-^Rl'lb^ 
55°  to  the  uprights,  which  angle  is  reduced 
by  the  pad'ding  of  the  ring  to  45°.     The 
'inside  upright  extends  from  the  peri- 
neum to  three  inches  below  the  sole 


Fig.  337. — Imperfect  Fixation  of  the  Knee,  by 
Plaster  Bandage. 


Fig.  338.— Thomas  Knee  Splint  for  Right  Leg,  pro- 
vided with  Leather  Lacings  (D),  Perineal  Ring  (.A), 
Strap  to  go  over  Shoulder  (E),  Foot  Piece  (C). 


of  the  foot.  The  outside  upright  extends  from  half-way  between 
the  crest  of  the  ilium  and  the  top  of  the  great  trochanter  to  three 
inches  below  the  sole  of  the  foot.  In  measuring  for  the  splint  the 
circumference  of  the  thigh  at  the  groin  should  be  measured  and 
allowance  made  for  padding  the  ring.  The  length  of  the  uprights 
and  the  places  on  the  ring  where  the  uprights  should  be  attached 
should  be  measured.  These  uprights  should  be  so  placed  as  to  be 
in  the  same  plane  as  the  shaft  of  the  femur. 


TUMOR   A/JU/S   U/'     'I'lllC  KNJ'JJC-JiJ/NT. 


177 


The  bar  at  the  bottom  of  the  splint  can  be  utih/-ed  as  a  means 
for  usin<^  traction  if  adhesive  plaster  is  ajjplied  to  the  leg  and  web- 
bing sewn  to  the  lower  end  ;  the  webbing  straps  are  buckled  tightly 
around  the  bar,  and  a  certain  amount  of  traction  can  be  exerted. 
This  mode  of  extension  is  not  shown  in  the  figure,  which  was  taken 

from  the  photograph  of 
a  case  where  traction  was 
not  required.  The  idea 
of  using  traction  is  not 
in  accordance  with  the 
views  of  the  inventor  of 
the  splint.  The  leg  can  be 
fixed  by  means  of  band- 
ages which   pass  around 


Fig.  339.  Fig.  340. 

Fig.  339. — Thomas  Knee  Splint  Applied. 

Fig.  340.— Appliance  for  Adjusting  the  Length  of  the  Thomas  Knee  Splint. 
Fig.  341. — Fi.xation  Appliance  for  the  Thomas  Knee  Splint. 


Fig.  341. 


the  leg  and  spl-int  or  by  means  of  leather  bands  attached  to  the 
splint  and  lacing  around  the  leg.  With  this  splint  applied,  the 
patient  sits  in  a  ring  supporting  the  perineum  while  uprights  run 
below  the  foot  and  bear  the  body  weight.  The  protected  limb 
can  then  be  fixed  by  means  of  the  bandages  or  leather  lacings  just 
spoken  of. 


378  ORTHOPEDIC  SURGERY. 

For  convenience  it  is  often  desirable  to  change  the  length  of  the 
splint,  and  this  can  be  done  by  the  addition  of  a  simple  arrange- 
ment devised  by  Dr.  H.  L.  Burrell.  The  uprights  are  made  of  two 
parts,  the  upper  one  passes  in  the  lower,  which  is  a  hollow  rod;  a 
thread  is  cut  in  the  upper  rod  and  a  nut  screwed  on  it ;  by  setting 
the  nut  at  a  higher  or  lower  point,  the  upright  is  practically  length- 
ened or  shortened,  while  the  inner  rod  is  prevented  from  dropping 
out  of  the  outer  hollow  rod,  by  means  of  a  screw  which  passing 
through  the  outer  rod  catches  the  inner  rod  and  holds  it  firmly. 
The  diagram  shows  the  construction  of  the  appliance  (Fig.  340). 

The  Thomas  splint  is  slung  from  the  shoulder  by  means  of  a 
strap  indicated  in  Fig.  339,  and  the  well  limb  is  raised  by  means 
of  a  cork,  wooden,  or  steel  patten. 

The  simple  posterior  addition  shown  in  the  figure  (341)  has  re- 
cently been  devised  by  Dr.  J.  E.  Goldthwaite,  formerly  House  Sur- 
geon at  the  Children's  Hospital,  which  contributes  much  to  the 
eflficiency  of  the  splint  in  fixing  the  limb  in  very  sensitive  cases.  It 
consists  simply  of  two  light  steel  strips  attached  to  the  uprights  of 
the  splint  and  covered  with  sole  leather  where  they  are  in  contact 
with  the  leg. 

When  the  condition  of  the  limb  has  improved  so  much  that  pain 
and  sensitiveness  are  absent,  the  Thomas  splint  can  be  shortened, 
and  the  ends  slotted  into  the  sole  of  the  shoe  at  such  a  place  that 
the  splint  is  too  long  for  the  heel  to  touch  the  ground,  and  in  this 
way  the  patient  w^alks  about  suspended  largely  by  the  perineal  ring 
and  bearing  but  little  weight  on  the  diseased  joint.  Then  grad- 
ually after  some  months  the  use  of  the  splint  may  be  discon- 
tinued. 

Counter-irritation  of  the  Knee. — Blisters,  iodine,  and  the  actual 
cautery  have  all  been  advised  in  the  treatment  of  tumor  albus  of 
the  knee.  Recently  trephining  of  the  bone  and  the  introduction 
of  a  galvano-cautery  into  the  cancellous  structure  of  the  bone  has 
been  advised  by  some  French  writers.  Slight  cauterization,  blis- 
ters, and  iodine  may  be  of  assistance  in  the  slighter  cases;  but  in 
severer  forms  of  epiphyseal  ostitis,  more  radical  measures  are 
needed.  The  introduction  of  the  actual  cautery  into  the  bone 
tissues  softened  by  ostitis  has  seemed  to  the  writers  to  have  a  bene- 
ficial effect  in  stimulating  the  development  of  a  cicatricial  granu- 
lating tissue,  but  only  in  connection  with  mechanical  treatment. 

Treatment  of  Complications. — Flexion  of  the  knee  is  the  most  com- 
mon and  the  most  troublesome  complication  of  tumor  albus.  It  is 
commonly  associated,  when  it  occurs,  in  the  early  part  of  the  dis- 
ease with  an  acutely  sensitive  condition  of  the  joint,  but  later  in 
the  history  it  may  come  on  insidiously  and  without  pain. 


TUMOR   ALT! US   O]'     -mi':    K N I'lE-JOTNT.  379 

The  means  of  strai^htcninci-  a  knee-joint  flexed  ljy  aeute  disease, 
may  be  classified  as  follows: 

1.  By  traction  in  the  line  of  the  defornn'ly  a]jj)lied  (a)  in  bed;  {b) 
while  the  patient  goes  about. 

2.  By  means  of  apparatus  forcibly  straightening  the  leg;  such 
as  the  Billroth  splint,  the  Thomas  knee  splint,  the  Stillman  sector 
splint,  etc. 

3.  By  simple  fixation  by  means  of  a  succession  of  plaster-of-Paris 
bandages. 

4.  By  straightening  under  ether. 

In  sensitive  cases  it  may  be  necessary  to  confine  the  patient  to 
bed.  Traction  by  weight  and  pulley  can  be  applied  to  the  leg  by 
means  of  adhesive  plaster  applied  below  the  knee,  the  leg  being 
supported  by  a  firm  cushion  under  the  knee  arranged  so  that  trac- 
tion comes  in  the  line  of  the  deformity.  After  a  subsidence  of  the 
spasm,  which  follows  very  soon  upon  the  application  of  traction, 
the  limb  can  be  made  straight  gradually  and  fixed  in  a  straight- 
ened position,  and  ambulatory  treatment  can  be  begun. 

Traction  in  the  line  of  the  deformity  can  be  applied  to  the  limb 
while  the  patient  goes  about  by  one  of  several  appliances  which 
are  more  or  less  expensive.  The  best  splint  is  one  already  alluded 
to,  similar  to  the  protection  splint  described  for  hip  disease.  It  is 
furnished  with  a  perineal  band  which  takes  the  body  weight  off  of 
the  l&g,  and  at  the  knee  is  a  lock  joint  which  can  be  set  at  any 
angle.  The  bottom  of  the  splint  goes  far  enough  below  the  foot 
to  protect  the  limb  from  jar  in  walking,  and  ends  in  a  traction  bar. 
The  splint  is  set  at  an  angle  corresponding  to  the  angular  de- 
formity of  the  affected  knee,  and  traction  is  made  upward  above 
the  knee  by  means  of  adhesive  plaster  attached  to  the  thigh  and 
buckling  on  to  the  splint,  and  extension  is  made  downward  below 
the  knee  by  a  plaster  extension  pulling  doAvn  to  the  traction  bar  at 
the  bottom  of  the  splint.  The  leg  is  fixed  in  the  splint  by  leather 
lacings  for  the  thighs  and  calf,  which  are  adjusted  after  the  exten- 
sion is  tightened. 

The  same  end  is  accomplished  by  Dr.  Shaffer's  knee  splint, 
which  at  the  same  time  makes  forward  pressure  against  the  head 
of  the  tibia.  It  is  shown  in  the  figure.  The  thigh  bands.  A,  A,  join 
the  leg  bands,  B,  B,  at  a  point  about  opposite  the  centre  of  motion 
at  the  knee,  i.e.,  opposite  the  condyles  of  the  femur.  Adhesive 
strips  being  applied  to  the  thigh,  they  are  secured  at  the  buckles, 
D,  D,  by  webbing  bands  which  pass  over  the  pulleys  at  E,  E.  At 
the  leg  the  buckles,  F,  F,  answer  the  same  purpose,  as  applied  to 
the  leg.  At  G  there  is  a  screw  by  which  the  relation  of  the  leg  to 
the  thigh  bands  may  be  changed  at  will,  and  at  H  there  is  a  trac- 


38o 


ORTHOPEDIC  SURGERY. 


tion  rod  which  acts  upon  the  post-tibial  band,  which  rests  against 
the  upper  end  of  the  tibia.  This  post-tibial  band  moves  upon  a 
remote  centre  at  K,  and  the  pressure  being  applied  by  the  traction 
rod  H,  B  and  I,  moves  downward  and  forward^  carrying  the  head 
of  the  tibia  with  it — a  severe  counter-traction  existing  at  the 
adhesive-plaster  resistance  and  at  the  webbing  straps  L,  which  pass 
over  the  lower  end  of  the  femur..  In  applying  this  instrument,  the 
screws  at  G  are  loosened,  and  the  leg  part  of  the  apparatus  falls 
back,  so  that  there  is  no  pressure  made  upon  the  tibia  at  all.  The 
adhesive  plaster  being  secured  by  its  webbing  ends  at  the  buckles 
D,  D,  and  the  femur  being  further  secured  by  tightening  the  web- 
bing band  L,  the  initial  force  is  applied  by  forcibly  extending  the 


Fi5.  342. — Shaffer's  Knee  Splint. 


rod  H,  until  the  head  of  the  tibia  is  pushed  forward  and  downward 
to  the  desired  extent.  Then  the  leg  traction  rods,  B,  B,  are  brought 
up  against  the  tibia,  and  the  screws  at  G  being  turned  by  a  key, 
are  secured  in  the  position  of  contact  with  the  leg,  the  leg  adhe- 
sive strips  being  secured  at  buckles,  E,  F.  Linear  traction  is  now 
made  by  the  double  traction  rods  of  the  two  leg  pieces  (M,  M),  the 
linear  traction  being  made  after  the  head  of  the  tibia  is  pushed 
fortvard  and  downward  by  the  rod  H. 

The  centre  of  motion  of  extending  the  leg  is  not  directly  at  the 
knee  but  above  the  joint,  and  several  appliances  have  been  devised 
to  straighten  the  limb  at  the  same  time  distracting  the  tibia  from 
the  femur.  A  powerful  one  of  this  sort  has  been  used  by  Dr.  Taylor, 
consisting  of  two  strong  wooden  elbows;  one  portion  is  attached 
to  the  thigh,  another  to  the  leg  by  means  of  adhesive  plaster,  and 
both  are  jointed  together  near  the  knee,  but  a  little  anterior  to  it. 


TUMOR  AL/WS   OF    TH l<:   KNI'll'l-JOfNT. 


381 


The  two  unattached  arms  which  project  from  these  act  as  levers^ 
and  if  made  to  approach  each  other,  extend  the  leg  at  the  knee. 

A  simple  appliance  of  this  sort  has  been  devised  by  Dr.  J,  F. 
Ridlon,  of  New  York.  A  screw  joint  above  the  knee  is  attached  to 
two  metal  arms,  and  one  is  attached  to  the  leg  and  another  to  the 
thigh  by  adhesive  plaster  extension.  By  means  of  the  screw  force 
the  arms  are  straightened,  and  the  joint  being  above  the  knee, 
motion  tends  to  pull  the  tibia  from  the  femur  when  the  angle  is 
straightened. 

Correction  by  Means  of  Apparatus  Forcibly  Straightening  the  Leg. 
— The  Billroth  splint  is  an  efilicicnt  means  of  overcoming  the  de- 


FiG. — 343. — Billroth  Splint  for  Straightening' 
the  Knee. 


Fig.  344. — Apparatus  for  Gradual  Forcible  Straightening 
of  Knee  Flexion. 


formity  in  cases  where  the  patients  can  be  kept  under  observation. 
A  plaster  bandage  is  applied  to  the  limb  in  which  are  incorporated 
two  hinged  iron  strips  attached  to  broad  plates.  The  bandage  is 
allowed  to  harden  and  then  the  front  over  the  knee  is  cut  out  and 
at  the  back  where  it  has  been  purposely  made  quite  solid,  a  trans- 
verse division  of  the  plaster  is  made.  Into  this  slit  are  inserted 
wedges  of  increasing  size  until  the  leg  is  straight.  The  splint  has 
to  be  watched  or  it  will  cause  sloughs,  as  it  exerts  considerable 
pressure. 

The  Thomas  knee  splint  can  be  used  to  correct  deformity :  the 
bandage  being  applied  in  front  of  the  thigh  and  the  knee  and 
behind  the  calf.  By  tightening  them,  the  limb  can  be  forced 
into  a  corrected  position.  This  is  the  method  advocated  by  ]\Ir. 
Thomas,  but   in   the  hands  of   the  writers  it  has  in   manv  cases  at 


382 


ORTHOPEDIC  SURGERY. 


once  started  an  acutely  sensitive  condition  of  the  joint.  For  this 
reason,  the  appliance  should,  however,  be  used  with  great  care,  as, 
if  injudicious  force  is  used,  an  acute  stage  of  arthritis  can  be  read- 
ily brought  about. 

With  proper  and  skilful  adjustment  of  the  bandage,  proper 
pressure  on  the  back  of  the  tibia  can  be  exercised;  but  if  too  great 
pressure  is  exerted  on  the  lower  part  of  the  leg,  and  too  little  on 
the  tibia,  the  head  of  the  tibia  may  be  crowded  against  the  end  of 
the  femur  and  the  epiphyseal  ostitis  increased. 

The  appliance  shown  in  the  accompanying   figure  furnishes  an 


Fig.  345.— Wire  Splint  for  the  Gradual  Correction  of  Knee  Flexion. 

efficient  mode  of  straightening  the  limb  in  cases  where  the  sensi- 
tiveness is  slight  and  close  observation  is  possible. 

The  figure  (345)  shows  a  simple  wire  splint,  which  is  useful  in 
correction  of  this  deformity  in  the  class  of  cases  where  the  sensi- 
tiveness is  not  great.  It  consists  of  a  wire  splint  to  which  the  thigh 
is  attached  ;  the  leg  is  pulled  upon  especially  behind  the  head  of 
the  tibia,  thereby  avoiding  the  uncomfortable  results  of  exerting 
the  straightening  force  wholly  from  the  lower  part  of  the  leg. 

Stillman  has  devised  what  is  termed  by  him  a  sector  splint,  which 
can  be  incorporated  in  a  plaster  bandage  or  secured  by  adhesive 
plaster  to  the  leg  and  thigh,  and  used  for  fixation  and  the  correc- 
tion of  deformity.  The  construction  of  the  apparatus  is  evident 
from  the  figure  (346). 


TUMOR   A/JWS   OI<     77//':   /<N li/'.-Jo/ j\'J\ 


l«3 


Other  appliances  are  recommended,  such  as  arc  represented  in  the 
accompanying  illustrations  (347  and  348).  They  are  all  defective 
mechanically  in  exerting  the  greatest  pressure  on  the  lower  end  of 
the  tibia  and  not  on  the  upper  part.  The  effect  of  this  is  to  crowd 
the  upper  edge  of  the  tibia 
against  the  femur  and  often 
to  exert  injurious  pressure. 

Reduction  of  Flexion  by  Fix 
ation  Bandages. — A  very  sim- 
ple way  to  straighten  a  knee- 
joint  flexed  by  disease,  when 
apparatus  cannot  be  afforded, 
is  by  simple  fixation  of  the 
knee-joint  by  means  of  a 
series  of  plaster  of  Paris  bandages.  These  should  be  applied  to 
the  knee  in  its  deformed  position  without  any  attempt  to  extend  it. 
It  will  be  often  found  in  the  lighter  cases  that  the  limb  can  be  made 
straighter  at  each  successive  bandage,  so  great  is  the  sedative  action 


Fig.  346. — Stillman's  Sector  Splint. 


Fig.  34S. 
Figs.  347  and  348. — Defective  Apparatus  for  the  Correction  of  Knee  Flexion. 

of  complete  fixation.     It  is  hardly  necessary  to  add  that  no  weight 

should  be  borne  upon  the  limb  during  the  process  of  straightening. 

Forcible  Reduction  by  Flexion. — -With  regard  to  the  straightening 

of  the  knee  under  an  anaesthetic  it  is  not  a  measure  to  be  adopted. 


384 


ORTHOPEDIC  SURGERY. 


unless  it  is  impossible  to  afford  time  for  gradual  straightening 
either  in  bed  or  while  the  patient  goes  about.  Much  pain  is  gen- 
erally occasioned  by  the  proceeding,  which  is  often  the  cause  of  an 
exacerbation  of  the  disease,  and  for  these  reasons  the  measure  is 
not  one  to  be  adopted. 

If  the  leg  is  allowed  to  remain  in  the  flexed  position,  angular 
ankylosis  will  probably  occur  as  shown  in  the  figures. 

Where  firm  adhesions  have  been  formed  at  the  knee-joint,  cor- 
rection by  means  of  appliances  will  be  found  tedious,  painful  and 
sometimes  impossible,  and  generally  forcible  correction  of  some  sort 
will  be  necessary  to  break  down  the  adhesions.     The  best  way  is 

to  break  down  the  adhesions 
by  forcibly  flexing  the  legj  and 
then  by  forcible  extension  to 
straighten  it.  The  danger  of 
rupturing  the  popliteal  artery, 
which  has    occurred,  is    in    this 


Fig.  349. — Angnlar  Ankylosis  of  Knee. 


Fig.  350. — Angular  Ankylosis  of  the  Knee, 


way  avoided.  Tenotomy  of  the  hamstring  tendons  in  many  cases 
should  be  employed  beforehand. 

Many  appliances  have  been  devised  to  give  greater  power  in 
forcible  correction.  The  following  procedure  will,  however,  be 
found  sufUcient:  The  patient  is  placed  upon  the  floor  upon  the 
back  and  the  surgeon  stands  over  the  patient  holding  the  flexed 
knee  with  both  hands,  the  fingers  being  placed  under  the  popliteal 
space.  The  whole  weight  of  the  surgeon's  trunk  can  be  thrown  upon 
the  end  of  the  lever  furnished  by  the  patient's  leg,  the  hands  of 
the  surgeon  pulling  upon  the  popliteal  space  furnishing  resistance. 

After  the  limb  has  yielded  and  the  adhesions  broken,  it  can  be 
straightened  if  the  patient  is  turned   upon  the  face;  a  downward 


TUMOR   ALB  US   UF    TJII'l  A'NKK-JO/A'T.  385 

force  being  applied  to  the  heel,  resistance  being  fu-rnished  by  a 
cushion  placed  under  the  patient's  knee.  Where  subluxation  is 
present  it  must  be  corrected. 

After  correction,  the  limb  should  be  well  surrounded  with  soft 
cotton  and  a  stiff  bandage  applied,  the  limb  being  held  straight 
until  the  plaster  has  become  hard.  The  procedure  is  sometimes 
followed  by  pain,  and  opiates  are  necessary  for  a  few  days.  In 
the  lighter  cases  no  such  force  is  required,  but  the  limb  can,  under 
an  anaesthetic,  be  brought  into  position  by  manual  manipulation 
with  very  little  risk. 

The  dangers  incurred  by  this  procedure  are  not  as  great  as  would 
be  supposed.  Such  a  violent  procedure  should  not  be  undertaken 
if  there  is  inflammation  present  at  the  joint,  but  in  the  early  acute 
stages  little  force  is  required  to  straighten  the  limb.  The  danger 
of  rupture  of  the  artery  can  be  avoided  by  care.  Separation  of  the 
epiphysis  of  the  femur  may  take  place,  but  is  cured  by  the  fixation 
requisite  to  treatment,  and  should  not  occur  if  the  force  is  care- 
fully applied.  Fracture  of  the  femur  and  tibia  can  be  avoided  by 
care.  Such  measures  are  not  required  except  in  extreme  resistant 
cases  presented  by  adolescents  or  young  adults. 

Jf  the  deformity,  flexion,  remains  uncorrected  in  severe  ostitis  of 
the  knee-joint,  a  subluxation  of  the  tibia  backward  takes  place,  due 
to  the  contraction  of  the  ham-string  muscles.  This  is  due  in  part 
to  the  spasm  of  the  ham-string  muscles,  which  have  pulled  the 
tibia  backward,  but  chiefly  to  the  fact  that  owing  to  adhesions  the 
flexed  tibia  is  unable  to  slide  forward  over  the  condyles  of  the 
femur,  as  happens  in  normal  extension.  Raising  the  leg  simply 
crowds  the  anterior  edge  of  the  tibia  into  the  condyles.  To  obvi- 
ate this  the  head  of  the  tibia  should  be  pressed  forward  and  upward 
to  the  same  degree  that  the  leg  is  raised. 

Several  means  have  been  used  to  effect  this.  The  writers  have 
found  the  method  illustrated  in  the  accompanying  diagrams  of  use 
in  the  most  obstinate  cases  (Figures  351  and  352). 

Pressure  forward  on  the  head  of  the  tibia  is  exerted  by  turning 
the  handle  A;  this,  by  means  of  a  screw  force,  pushes  the  plate  C 
forward,  working  through  the  band  B.  The  calf  muscles  protect 
the  artery  and  nerve  from  injurious  pressure.  Counter-pressure  is 
secured  by  means  of  leather  straps  D  and  E,  which  are  passed  re- 
spectively over  the  knee  and  leg,  protected  by  a  thick  layer  of  sad- 
dler's felt.  Several  straps  will  be  needed  at  the  knee  to  prevent 
loss  of  counter-pressure,  as  the  limb  is  made  straighter.  Another 
strap,  F,  under  the  leg,  secures  the  lower  part  of  the  leg.  The 
side  bars,  bands,  and  plate  of  the  apparatus  should  be  of  strong 
steel. 

25 


ORTHOPEDIC  SURGERY. 


The  apparatus  is  put  on  the  limb  in  a  flexed  position  (after  rup- 
turing adhesions  by  forcible  flexion  if  that  is  needed),  the  head  of 
the  tibia  is  pushed  forward  as  far  as  is  advisable,  and,  by  means  of 

the  end  of  the  appliance, 
which  serves  as  a  handle, 
the  leg  is  extended;  the 
pressure  forward  of  the 
head  of  the  tibia  can  be 
increased,  and  the  counter- 
pressure  regulated  if  nec- 
essary, by  loosening  such 
of  the  straps  D  D  as  ex- 
tension of  the  limb  may 
tighten  too  much.  When 
the  limb  is  partly  cor- 
rected, strong  downward 
pressure  on  the  femur  will 
be  needed.  This  can  be 
secured  by  means  of  a 
strap,  which,  passing  over 
the  knee  (protected  by 
padding),  is  secured  below 
to  the  floor  or  to  a  strong  rod,  H,  on  which  the  operator  or  his 
assistant  can  place  his  foot,  regulating  the  amount  of  pressure. 

Experiments  on  the  cadaver  which  were  conducted  at  the  Har- 
vard Medical  School,  through  the  courtesy  of  Drs.  C.  B.  Porter  and 
T.  Dwight,  showed  that  by  means  of  this  appliance  the  tibia  could 
readily  be  pushed  forward  to  any  desired  extent.  On  normal 
joints,  the  tibia  can  be  pushed  forward  to  a  considerable  distance 


Fig.  351. 


Fig. 


Fig.  353. — Result  after  Correction  of  Right-Angled  Contraction  of  the  Knee. 

without  rupturing  the  ligaments.  The  appliance  has  been  em- 
ployed successfully  in  several  severe  cases.  In  one  instance  a 
right-angled  contraction  after  tubercular  disease  had  existed  for 
sixteen   years.     In   another   of  seven  years'   duration,  suppuration 


TUMOR  Ai.r.irs  ()!•   I'ifi-:  Kj\'h:i-:-j()i.vT. 


3^7 


and  a  sinus  havini^-  been  present  for  five  years.'  The  result  of  forci- 
ble correcticjn  by  this  method  in  the  first  case  is  shown  in  tlic 
figure  (343). 

Resection  of  the  K lice. —  Poinsat  states  that  in  France  the  opera- 
tion of  resection  of  the  knee  has  not  been  in  favor,  chiefly  on 
account  of  the  successful  results  of  redressement  force  and  the 
influence  of  the  authority  of  j^onnet.  He  says  that  although  forc- 
ible straightening  is  effectual  in  a  large  number  of  cases,  in  a  few 
cases  rupture  of  the  vessels,  injury  of  the  nerve,  and  unfortunate 
results  have  followed.  Poinsat  regards  redressement  force  as  con- 
traindicated,  also  in  ankylosis  in  young  persons,  where  hypertrophy 
of  the  condyles  usually  follows  the  subluxation 
of  the  femur  backward,  which  frees  the  femur 
from  pressure. 

In  these  cases  two  operative  procedures  are 
to  be  considered,  osteotomy  of  the  femur  and  re- 
section. Of  these  he  believes  resection  to  be  pre- 
ferable, for  the  reason  that  in  this  operation  the 
joint  is  opened  and  all  diseased  tissue  is  removed, 
and  the  possibility  of  subsequent  inflammation  is 
obviated.  He  has  collected  seventy-seven  cases, 
and  found  a  mortality  from  the  operation  of 
eight  per  cent.  The  results  where  antiseptic  pre- 
cautions were  employed  were  more  favorable 
(thirty-six  operations  and  no  death). 

Poinsat  regards  the   operation  as  entirely  free 
from   danger  in  patients   under   fifteen  years  of 
age,  but    success  has    been    obtained    in    adults. 
Six    cures  are   reported   between    forty  and  fifty  years,   and   one 
fifty-seven  years  old."" 

The  technical  details  of  resection  will  be  described  later.  Here 
it  will  be  sufficient  to  state  that  the  experience  of  the  writers  coin- 
cides in  the  main  with  those  of  Poinsat.  Resection,  ho^\•ever, 
should  be  reserved  for  cases  of  bony  ankylosis  and  should  only  be 
done  in  adults. 

When  flexion  has  become  permanent  and  the  patient  is  unwilling 
to  undergo  an  operation,  the  apparatus  shown  in  the  diagram  ren- 
ders much  assistance  in  walking. 

Abscess. — The  treatment  of  peri-articular  abscess  is  the  same  that 
is  recommended  for  the  treatment  of  abscess  at  the  hip,  and  as  thor- 
ough a  cleaning  out  as  possible  should  be  undertaken.     They  are 


Fig.  354. — Apparatus  for 
Assistance  in  Contraction 
of  the  Knee. 


'  Report  City  Hospital,  Boston.     Fourth  series. 

^  Bull,  et  Mem.  de  la  Societe  de  Chir. ,  vol.  v.,  p.  461. 


388  ORTHOPEDIC  SURGERY. 

generally  superficial  and  do  not  dissect  about  between  the  muscles 
to  the  extent  that  hip  abscesses  often  do. 

Operative  Treatment  of  Tiiinor  Albiis. 
The  operative  measures  to  be  considered  are  : 

(i)  Excision. 

(2)  Arthrectomy. 

(3)  Amputation  of  the  leg 

Excisiofi  of  the  Knee-joint. — The  first  public  proposition  to  excise 
the  knee-joint  was  made  in  a  letter  written  by  Mr.  Park,  of  Liver- 
pool, to  Mr.  Percival  Pott,  of  London,  dated  Sept.  i8th,  1782,  and 
entitled  for  publication,  "An  Account  of  a  New  Method  of  Healing 
Diseases  of  the  Joints," 

In  1781,  Mr.  Park  did  some  experimenting  upon  the  dead  sub- 
ject in  order  if  possible  to  determine  the  very  best  method  of  doing 
this  operation,  and  shortly  after  he  did  the  operation  successfully 
upon  an  adult.  Since  that  time  the  operation  has  gradually  come 
into  greater  and  greater  favor. 

The  diminished  mortality  after  excision  of  the  knee-joint  for  dis- 
ease is  largely  due  to  improved  technique,  especially  to  the  intro- 
duction of  antiseptic  measures.  Ollier's'  mortality  has  fallen  from 
eighty  to  fourteen  per  cent  since  antiseptic  precautions  were 
adopted. 

Mensing's  cases  show  clearly  the  same  point.- 

In  80  cases  he  found  that 

1.  Before  antiseptic  surgery  and  the  use  of  the  bloodless 

method  of  operating,  the  mortality  was,        .         .     33  per  cent. 

2.  After  antiseptic  surgery  was  introduced  the  mortality 

was,  .........       8.5     " 

3.  Since  the   introduction   of  permanent   dressings,  the 

mortality  was,         .......       2        " 

Of  329  cases  of  knee-joint  excision  done  with  antiseptic  precau- 
tions for  disease,  9.42  per  cent  died.^  But  the  mortality  per  cent  is 
most  strikingly  affected  by  the  age  of  the  patients  as  shown  in  the 
tables  of  Culbertson,  who  found,  in  the  analysis  of  between  600  and 
700  cases  of  knee-joint  excision  done  in  general  practice  for  all 
causes,  that  the  percentage  of  deaths  varies  as  follows : 

'Oilier:  Rev.  de  Chin,  1884,  p.  157. 

^Centr.  f.  Chir.,  i883,,No.  49. 

3  A.  M.  Phelps:  N.  Y.  State  Soc.  Trans.,  1886,  p.  586. 


TUMOR   A/JU/S    ()/'■    77//':   /<N IC/'.-JO/ NT. 


389 


Mortality. 

•       38.9 

per  cent 

.       16.2 

.       17,2 

•       30.1 

"       " 

•     39-4 

t<            u 

.     17- 

U                 11 

•     4'-5 

U                 11 

.         .     52.6 

Under  5  years, 

From     5  to  10  years, 
10  to  15 

15  to  20  " 

20  to  25  " 

25  to  30  " 

30  to  40  '' 

Over  40  " 


The  average  of  all  being  29.(8      "       " 

In  Mensing's'  eighty  cases  of  total  and  three  of  partial  resection 
of  the  knee,  operated  upon  at  Kiel,  and  nine  operations  of  removal 
of  a  wedge-shaped  piece  of  bone  for  rectangular  ankylosis,  forty- 
eight  (52.01  per  cent)  were  discharged  well.  The  average  shorten- 
ing was  two  and  one-half  centimetres,  and  flexion  only  occurred  in 
two  cases;  two  had  good  motion ;  one  only  slight  motion.  From 
thirty-two  of  these,  later  information  as  to  their  condition  was  ob- 
tained, and  in  three  cases  a  moderate  flexion  had  taken  place;  in 
two  a  relapse  had  occurred,  followed  in  one  case  by  a  second  re- 
section, and  in  another  by  amputation.  In  thirty-four  patients  the 
excision  was  not  perfectly  successful  (that  is,  thirty-seven  per  cent), 
fourteen  undergoing  a  subsequent  amputation,  and  twenty  having 
an  unhealed  sinus  at  the  time  the  patients  left  the  hospital.  Of 
these  twenty  the  ultimate  results  of  thirteen  were  obtained :  in  ten 
cicatrization  took  place;  three  died.  Of  the  fourteen  secondary 
amputations  ten  recovered,  and  two  died.  Ten  patients  who  under- 
went excision  at  the  clinic  died  directly  from  the  operation. 

Statistics  in  regard  to  the  ultimate  results  of  conservative  treat- 
ment of  disease  of  the  knee  are  unfortunately  of  little  value  as  a 
guide  in  the  consideration  of  proper  treatment  of  disease  of  the 
knee-joint ;  it  may  be  said,  however,  that  conservative  treatment  in 
children  gives  most  excellent  results  in  cases  which  can  be  watched 
and  treated  for  a  long  time.  The  following  figures  are  given  by 
Willemer  of  eases  treated  in  the  course  of  seven  years  at  the 
Gottingen  Clinic.- 

The  treatment  was  fixation  by  plaster-of-Paris  bandages  preceded 
by  extension,  with  or  without  incision  of  abscesses,  curetting,  etc.  ; 
or  by  resection,  partial  or  complete;  or  amputation.  Of  the 
cases  not  operated  upon,  in  three  years  19  per  cent  recovered,  15 
per  cent  died,  and  66  per  cent  were  still  under  treatment.  In  four 
years,  26  per  cent  had  recovered,  17  per  cent  had  died,  and  57  per 

'  Centralblatt  f.  Chirurgie.  No.  49,  December  Sth,  1SS3. 
=  Deutsche  Zeitschr.  f.  Chin,  1SS5,  Bd.  21,  Heft  4. 


390 


ORTHOPEDIC  SURGERY. 


cent  were  uncured.  At  the  end  of  five  years,  including  all  cases 
operated  on  or  not,  29  per  cent  remained  not  well,  11  per  cent  had 
been  amputated  (with  a  mortality  of  60  per  cent),  37  per  cent  had 
been  resected  (with  a  mortality  of  51  per  cent),  and  13  per  cent 
were  well  without  operation. 

It  should  be  borne  in  mind  that  these  figures  represent  hospital 
cases,  presumably  cases  treated  under  more  or  less  unfavorable 
circumstances. 

It  would  be  fair  to  assert  that  in  children,  between  5  and  20,  the 
mortality  from  the  operation,  near  and  remote,  would  not  be  far 
from  10  per  cent,  being  less  rather  than  more  than  this  percentage. 

The  functional  results  after  excision  are,  however,  decidedly  in- 
ferior to  the  results  after  conservative  treatment.  Ankylosis  is  to 
be  hoped  for  after  excision  and  is  complicated  by  a  tendency  to 
flexion  of  the  apparently  ankylosed  joint.  In  130  cases  analyzed 
by  Hoffa,  there  were  14  cases  of  slight  flexion  and  30  cases  of 
severe  flexion  noted  when  the  end  results  were  considered.  This 
of  course  is  a  very  serious  matter  and  should  make  the  surgeon 
very  careful  about  removing  splints  before  there  is  reason  to  be- 
lieve that  firm  bony  ankylosis  is  present.  This  generally  occurs 
after  apparent  union  has  taken  place  and  the  patient  has  been  dis- 
charged from  immediate  supervision. 

It  may  be  said  with  regard  to  the  amount  of  shortening  after 
excision  in  cases  where  the  epiphyseal  lines  are  saved  that  it  is  likely 
to  be  only  moderate,  although  even  then  it  is  m.ore  than  after  con- 
servative treatment.  In  the  cases  of  Hoffa'  where  both  epiphyseal 
lines  had  been  removed  by  operation,  the  shortening  was  extreme, 
e.g.,  8  inches  in  10  years,  3  inches  in  2  years,  etc.  Where  only  one 
line  is  removed  and  the  one  in  the  other  bone  left,  there  is  short- 
ening, but  less;  5  inches  in  6  years,  2  inches  in  i)^  years,  etc. 
When  both  epiphyseal  lines  were  saved  the  cases  showed  much 
less  tendency  to  progressive  shortening,  inside  of  2  years  after 
operation,  it  never  exceeded  5  cm.  (i^  inches),  and  in  the  worst 
case  of  all  it  was  only  4  inches  and  a  fraction  after  6  years,  while 
many  older  cases  showed  less  shortening. 

It  would  not  be  fair,  however,  to  dismiss  the  subject  without 
adding  that  severe  tumor  albus  without  resection  may  cause  serious 
arrest  of  growth  in  the  bones  in  cases  which  heal.  Nine  such  cases 
are  reported  by  Caumont  where  it  ranged  from  i  to  131^  cm.  (^ 
of  an  inch  to  4  inches).  But  the  shortening  after  extensive  exci- 
sion is  far  greater  in  general  than  after  a  spontaneous  cure,  Konig's 
rule  is  most  valuable  in  this  regard :  "  Saw  off  inside  the  extent  of 
the  cartilage." 
__J^"  'Arch.  f.  Klin.  Chir.,  1885,  iv.,  32. 


TUMOR   AT. BUS   Ol'    Tlfl'.    I< NEK-JO  TNT. 


391 


The  operation  of  excision  of  tlic  knee-joint  is  performed  as  fol- 
lows: 

The  leg  shcjuld  be  carefully  prepared  as  fcjr  any  antiseptic  ope- 
ration. The  use  of  the  Esmarch  bandage  and  tourniquet  is  optional 
and  is  not  an  essential.  With  it  the  operator  can  see  more  plainly 
where  the  disease  lies  and  the  operation  is  cleaner  and  quickx-r. 
But  its  use  encourages  the  after-bleeding,  which  is  considerable  in 
any  event,  and  after  the  application  of  the  dressing,  when  the  band- 
age has  been  used,  it  may  be  troublesome.  If  the  rubber  bandage 
is  applied  tightly  over  the  knee,  there  is  some  risk  of  forcing  the 
tuberculous  material  into  surrounding  structures.  Therefore,  if  it 
is  used,  it  should  be  omitted  over  the  knee-joint;  without  the  use 


Fig.  355. — Semilunar  Incision  for  Knee  Resection. 


Fig.  356. — Ollier's  Incision. 


of  the  bandage   there  is  rarely  any  hemorrhage  of  much  account 
and  much  less  staining  of  the  dressing  results. 

Three  incisions  are  commonly  employed,  each  of  which  is  favored 
by  a  certain  number  of  operators.  They  are :  {a)  the  semilunar  in- 
cision, which  passes  with  a  downward  curve  from  one  condyle  of 
the  femur  to  the  other,  the  lower  part  of  the  incision  crosses  the 
ligamentum  patella  at  its  middle  point ;  {h)  the  transverse  incision 
is  carried  directly  from  one  condyle  to  the  other  across  the  middle 
of  the  patella,  which  is  divided  transversely  with  a  saw ;  {c)  Ollier's 
sub-periosteal  method  demands  a  more  complicated  incision  which 
begins  two  inches  above  and  to  the  outer  side  of  the  patella  and  is 
carried  down  to  the  upper  and  outer  angle  of  that  bone  and  then 
along  its  outer  edge  and  that  of  the  ligamentum  patellae  until  the 
tuberosity  of  the  tibia  is  reached.  In  this  mode  of  operation  the 
periosteum  Avith  the  muscular  attachments  is  cleared  from  the 
bones  and  the  patella  carried  to  the  inside,  while  the  ligaments  are 


392 


ORTHOPEDIC  SURGERY. 


cut  and  the  ends  of  the  bones  protruded  through  the  incision-  all 
of  the  incisions  should  reach  the  bone  throughout  their  length  at 
the  first  cut.  In  the  semilunar  and  transverse  incisions  flaps  are 
dissected  up  exposing  the  front  of  the  joint,  the  capsule  is  divided, 
the  crucial  ligaments  cut  close  to  their  tibial  attachm.ent,  and  then 
the  lateral  ligaments  are  also  divided  and  the  end  of  the  femur 
cleared  so  that  it  can  be  portruded  through  the  incision  and  as 
much  as  seems  desirable  sawed  off.  In  the  same  way  the  tibia  is 
cleared  and  protruded  as  a  safeguard  against  injuring  the  popliteal 
vessels.  It  is  well  not  to  saw  quite  through  to  the  posterior  aspect 
of  the  bones,  but  to  saw  nearly  through  and  then  to  break  off  the 
slice  with  a  periosteum  elevator. 

Two  further  incisions  should  be  mentioned,  one  of  which  con- 
sists of  two  longitudinal  incisions,  or  one  straight  median  incision 
dividing  the  patella.  This  is  especially  useful  in  partial  excision 
or  arthrectomy.  The  other  is  Halm's  supra-patellar  incision,  which 
is  the  semilunar  incision  described  above  with  the  curve  upward. 
It  is  especially  advocated  as  giving  access  to  the  upper  part  of  the 
joint  sac.  Mitchell  Banks  departs  from  common  custom  in  dove- 
tailing the  femur  into  the  tibia  by  cutting  a  concavity  in  the  tibia 
with  a  butcher's  saw  and  cutting  the  femur  to  fit  into  it.  It  is  not 
an  easy  matter  to  do  this  and  it  adds  much  to  the  difficulty  of  the 
operation.  In  any  case  the  patella  should  be  removed  if  it  is  dis- 
eased, or  if  it  has  been  divided  in  the  operation  the  halves  should 
be  sewed  together  with  silver  wire  or  catgut.  As  to  drainage, 
there  is  no  need  of  the  posterior  counter-opening  made  by  some 
surgeons,  for  drainage  is  perfectly  good  if  the  incision  begins  far 
enough  back  on  the  leg. 

The  question  of  fixation  of  the  limb  after  operation  is  the  one 
difificulty  to  be  met  in  the  operation,  and  the  proposed  methods  of 
overcoming  this  are  numberless.  Riedinger' would  saw  off  the 
posterior  aspect  of  the  patella  and  refresh  the  corresponding  ante- 
rior surface  of  the  femur  and  tibia,  and  then  placing  the  patella  in 
close  contact  with  these  bones,  nail  it  to  the  femur  and  the  tibia 
by  two  steel  nails  driven  straight  in. 

It  is  impossible  to  say  how  thick  a  section  should  be  removed 
from  the  ends  of  the  bones.  In  adults  it  matters  not  whether  the 
section  goes  beyond  the  epiphysis  so  long  as  all  the  diseased  tissue 
is  removed.  In  children  only  very  ex,ceptionally  is  one  justified  in 
crossing  the  epiphyseal  line.  It  is  best  at  first  to  remove  a  very 
thin  section,  just  enough  to  take  all  the  articular  surface  of  both 
bones,  and  then  to  remove  another  section  if  the  disease  is  very 

'Cent.  f.  Chir.,  1887,  p.  440. 


TUMOR  ALU  US  ()/''    Till-:   K Mr: [■:-/()! NT. 


393 


extensive,  or  if  only  foci  of  disease  are  seen  to  scooj)  them  out  ex- 
tensively with  a  shar[)  spoon. 

It  is  of  the  utmost  importance  to  attend  carefully  to  the  plane 
of  section  which  the  saw  makes  in  reniovin[^  the  articular  surfaces. 
If  these  planes  are  ever  so  slightly  oblicjue  the  whole  axis  of  the 
limb  is  distorted  and  the  line  of  weif^ht-bearing  is  wrong  and 
tends  to  cause  angular  deformity  at  the  knee.  !n  tlie  femur  the 
plane  of  section  should  be  parallel  to  the  articular  surface  and  not 
perpendicular  to  the  shaft  of  the  bone,  which  would  make  it  oblique 
at  the  joint.  As  soon  as  section  of  the  bones  has  been  made,  the 
new  surfaces  should  be  placed  in  contact  and  the 
line  of  the  limb  carefully  observed. 

The  commoner  custom  has  always  been  to  wire 
the  bones  together,  and  of  late  the  use  of  steel  nails 
or  bone  pins  has  been  much  advocated.  Smooth 
French  box  nails,  three  inches  long,  answer  very 
well  and  contribute  a  fair  amount  of  fixation  to 
the  limb.  They  are  driven  in  obliquely  and  across; 
two  or  three  are  generally  enough  and  they  can  be 
driven  in  any  direction  in  which  they  seem  likely 
to  hold.  Mr.  Stoker '  uses  silver  dowels  which  run 
in  the  length  of  the  limb  without  crossing.  Any 
of  these  methods  are  likely  at  any  time  to  prove 
unsatisfactory;  but  at  times  they  will  be  found  to 
be  of  assistance.  ^  d  ,.•      * 

Fig.  357. — Relation  of 

Another  method  is  to  incorporate  light  splints  p.one  Sections  to  the  Epi- 
in  the  dressing,  which  shall  fix  the  limb  without  p'^^'^'" 
the  use  of  nails  or  wire.  Mr.  Marsh  advocates  the  use  of  an  out- 
side and  posterior  splint  in  addition  to  bone  knitting  needles,  which 
are  driven  into  the  femur  and  tibia  with  a  bradawl.  This  is  to 
counteract  the  tendency  which  the  femur  always  has  to  ride  up 
and  away  from  the  tibia.  In  general,  however,  plaster  of  Paris 
forms  the  most  satisfactory  splint  put  on  over  a  heavy  antisep- 
tic dressing,  the  bones  having  been  nailed  together  and  the  limb 
after  that  handled  very  carefully.  The  only  objection  to  it  is  that 
in  the  profuse  discharge  of  serum  which  takes  place  necessarily 
from  so  large  a  wound  within  the  first  twenty-four  hours,  the 
plaster  is  likely  to  be  stained  through  and  may  have  to  be  changed. 
But  if  a  sufficiently  heavy  dressing  is  put  on,  this  will  ordinarily 
not  happen  to  any  extent  or  if  it  does  a  light  dressing  can  be  ap- 
plied outside  to  protect  the  stained  spot.  Occasionally  the  plan  is 
useful  to  dress  the  limb  after  operation  in  a  heavy  dressing  and  on 
the  next  day  to  redress  it  and  apply  the  plaster.  In  this  way 
^  Brit.  Med.  Journ.,  Apr.  2d,  1SS7. 


394 


ORTHOPEDIC  SURGERY. 


one  may  be  almost  sure  of  a  dressing  which  can  be  left  on  almost 
indefinitely,  provided  the  operation  has  been  aseptic. 

There  are  two  precautions  to  be  observed  in  putting  the  leg  up 
in  splints  or  in  plaster;  first,  the  tendency  to  eversion,  and  second, 
the  tendency  to  dropping  backward  of  the  head  of  the  tibia.  With 
moderate  precautions  these  deformities  may  be  avoided.  When 
the  bones  are  wired  together,  if  the  holes  which  are  bored  in  the 
tibia  for  the  insertion  of  the  wire  are  placed  well  backward  and  the 
corresponding  holes  in  the  femur  well  forward,  much  will  be  done  to 
counteract  this  backward  displacement  of  the  leg  upon  the  thigh. 

The  late  after-treatment  of  excision  requires  no  comment.     The 

only    danger   that    exists    is    that 

upon    the 


limb  too  soon  before  firm  bony 
ankylosis  may  have  occurred.  It 
is  much  the  wiser  course  to  have 
the  patient  wear  a  perineal  crutch 
(in  the  form  of  a  Thomas  knee- 
splint)  which  shall  prevent  bearing 
any  weight  on  the  leg  until  several 
months  after  operation.  If  this 
precaution  is  neglected,  permanent 


Fig.  358. — Result  of  Excision  of  the  Knee  for 
Old  Tumor  Albus. 


Fig.  359. — Excision  of  the  Knee  with  the  Removal 
of  Wedge  of  bone,  (a)  From  the  Femur  or  (6}  from 
the  Joint  Plane. 


flexion  of  the  limb  is  likely  to  occur  or  a  lighting  up  of  the 
original  disease. 

Excision  of  the  Knee  for  Angular  Ankylosis. — Where  excision  of 
the  knee  is  done  for  angular  ankylosis,  the  only  modification  of 
the  operation  which  is  necessary  is  the  removal  of  a  wedge  of  bone 
large  enough  to  allow  the  ends  of  the  bone  to  come  together,  so 
that  the  angularity  is  obliterated. 

The  diagram  shows  the  common  method  of  such  an  operation. 
The  knee  is  exposed  as  for  simple  excision,  except  that  a  more 
extensive  flap  is  made,  and  then  a  wedge  of  bone  is  sawed  out,  of 
the  required  size  to  allow  the  knee  to  be  straightened.  The  after- 
treatment  is  the  same  as  in  an  ordinary  excision. 


TUMOR  AJJiUS  ()/'    ■/■///':  KX  I'll-:-/ or  NT.  395 

Arthrcctoiiiy. — As  a  substitute  for  excision,  vvliat  has  ?jeen  termed 
arthrectoiny  or  erasion  has  been  recommended  and  emph^.yed  by 
Volkmann  and  Schede,  Wri^dit  of  Manchester,  Gerster,  Duncan 
and  others.  The  method  has  been  also  termed  arthrotomy,  but 
it  differs  essentially  from  a  simple  incision  of  tiie  joint,  and  the 
term  arthrectomy  is  preferable.  Erasion  is  a  misleading  term  and 
has  not  found  general  acceptance. 

Arthrectomy  consists  of  the  removal  of  all  palpable  and  obvious 
portions  of  diseased  tissue,  whether  in  the  synovial  membrane  or 
elsewhere,  leaving  what  appears  to  be  healthy  tissue.  Two  advan- 
tages are  claimed  for  this  operation  over  excision:  (i)  That  it 
does  not  interfere  with  the  growth  of  the  limb,  and  (2)  that  mobility 
of  the  joint  may  be  preserved,  but  it  may  be  added  that  this  is  an 
exceptional  event  and  not  altogether  so  desirable  or  safe  an  ending 
as  bony  ankylosis.  The  objection  to  the  operation  is  that  it  is  not 
thorough,  and  oftener  than  excision  fails  to  eradicate  the  disease. 

Miiller  has  collected  22  operations;  i  died  of  chloroform  poison- 
ing, I  died  of  iodoform  poisoning,  2  died  of  general  tuberculosis 
from  eight  to  eighteen  months  after  the  operation  on  the  knee, 
which  had  been  successful,  15  healed  by  first  intention  without  a 
fistula  in  from  three  to  ten  weeks,  and  the  others  a  small  fistula  re- 
mained after  the  first  operation  and  a  subsequent  curetting  was 
necessary  before  recovery  took  place.  No  shortening  followed  the 
operation  in  6;  the  knee  remained  stiff,  but  in  2  there  was  a  cer- 
tain amount  of  motion  possible,' 

Duncan"  reports  8  cases  of  arthrectomy  with  2  recurrences,  and 
4  ankylosed  knee-joints.  One  patient,  aged  21,  recovered  with 
motion  at  the  knee  to  a  right  angle  and  another  wnth  very  slight 
motion. 

The  operation  only  offers  advantage  over  excision  in  the  case  of 
cliildren,  and  chiefly  before  the  disease  has  made  extensive  pro- 
gress. It  is  easy  to  see  that,  if  any  extensive  disease  of  the  bone  is 
present,  any  measure  short  of  thorough  removal  must  necessarily 
fail.  The  operation  is,  therefore,  not  suited  to  cases  where  there  are 
many  sinuses  and  bone  enlargement,  but  to  cases  which  do  not  pro 
gress  favorably  under  conservative  treatment  faithfully  carried  out. 

In  the  matter  of  risk  there  is  little  to  choose  between  this  opera- 
tion and  excision,  for  the  immediate  death  rate  under  proper  pre- 
cautions is  very  small  in  both  operations.  The  risk  of  operative 
tubercular  infection,  alluded  to  so  often  in  speaking  of  operations 
upon  tuberculous  joints,  is  present  in  arthrectomy  as  in  excisions. 

^  Volkmann  and  Oilier:  Revue   de   Chirurgie,  No.  3,  1885  ;  Centralblatt   f.  Chirur- 
gie,  No.  9,  1885  ;  Centralblatt  f.  Chirurgie,  No.  48,  1SS4. 
^  Am.  J.  Med.  Sciences,  April,  iSSg,  p.  369. 


396  ORTHOPEDIC  SURGERY. 

The  operation  itself  may  be  described  as  follows:  The  joint  is 
opened  as  in  cases  of  excision  and  the  whole  synovial  membrane  as 
far  as  it  is  tuberculous  should  be  dissected  out;  if  carious  spots 
are  found  in  the  bone,  these  foci  should  be  removed  by  the  curette 
or  chisel.  If  the  whole  epiphysis  is  diseased,  excision  is  of  course 
unavoidable,  but  in  many  cases  this  is  unnecessary.  Schede,  Volk- 
mann,  and  others  have  reported  cases  of  excellent  recovery  with 
complete  healing  without  suppuration  in  a  few  cases  of  this  sort, 
and  similar  success  has  followed  the  procedure  in  two  cases  in  the 
practice  of  the  writers.  Strict  asepsis  is  essential,  as  well  as  a 
thorough  removal  of  all  tuberculous  tissue  in  the  affected  joint, 
necessitating  sometimes  complete  dissection  and  removal  of  all  of 
the  synovial  membrane,  as  well  as  carefully  curetting  the  bone. 
The  patella  should  be  removed  or  left  according  to  its  condition. 
Either  two  straight  incisions,  one  median  incision,  or  a  cross  inci- 
sion are  used.  The  patella  may  be  divided  and  subsequently  wired, 
or  the  ligamentum  patellse  cut  across.  All  tubercular  tissue  should 
be  removed  by  the  chisel,  curette,  or  scissors. 

The  parts  of  the  knee-joint  to  be  most  carefully  investigated 
for  diseased  foci  are  the  synovial  pockets  and  the  epiphyseal  lines 
of  the  femur  and  tibia  at  their  lateral  aspects.  Here  one  may  find 
foci  of  tuberculous  material  extending  into  the  epiphysis,  without, 
however,  in  most  cases  crossing  the  epiphyseal  lines. 

The  after-treatment  should  be  like  that  of  excision,  except  that 
wiring  or  nailing  the  bones  together  is  not  necessary,  as  the  liga- 
ments should  be  preserved. 

Flexion  of  the  limb  may  follow  arthrectomy  as  well  as  excision 
in  cases  where  protection  to  the  joint  has  been  discontinued  too 
early,  so  that  the  after-treatment  should  be  as  careful  and  as  pro- 
longed as  after  excision  of  the  joint. 

(3)  Amputation. — In  cases  of  extreme  disease  of  the  knee-jo''"!^ 
amputation  of  the  thigh  is  necessary  as  a  life-saving  measure.  As 
for  the  indications  determining  a  choice  between  excision  and  am- 
putation, it  can  be  said  that  where  the  patient's  reparative  power 
is  slight  an  amputation  is  to  be  preferred.  The  question  is  largely 
one  of  individual  judgment  ;  if  excision  is  first  tried  and  fails  to 
arrest  the  disease  and  finally  amputation  has  to  be  performed,  the 
patient's  chances  are,  of  course,  injured  by  the  choice  of  excision  in 
the  first  place.  In  the  adult,  extensive  removal  of  the  bones  may 
be  accomplished  by  excision  without  any  danger  of  arrest  of  growth, 
and  few  patients  can  be  brought  to  consent  to  amputation  of  a  limb 
so  long  as  any  other  method  of  treatment  holds  out  the  faintest 
prospect  of  relief.  In  children  amputation  should  be  deferred  to 
the  last  moment  and  excision  given  the  preference,  unless  the  erad- 


TUMOR   A  LB  US   OI'     Till'.    K NEK-JO  [NT.  397 

ication   of  the  disease  would    necessitate  tlie   removal   of  so  much 
bone  that  a  useless  leg  would  result  from  that. 

In  children,  therefore,  the  operation  could  only  he  advised  when 
the  joint  was  hopelessly  disorganized  and  so  much  (jf  the  shaft  of 
the  long  bones  was  evidently  diseased  that  an  excision  was  not 
practicable.     Such  cases  are  uncommon. 

Summary. 

The  treatment  of  tumor  albus  should  consist  m  fixation  of  the 
diseased  joint  by  plaster  of  Paris  or  some  suitable  splint,  with  trac- 
tion in  cases  where  the  muscular  spasm  is  very  marked.  If  ambu- 
latory treatment  is  to  be  undertaken  (which  is  almost  invariably 
to  be  advised),  protectio7i  is  also  necessary.  This  is  furnished  by 
the  Thomas  splint,  a  high  shoe  and  crutches,  or  by  the  use  of  a 
similar  protection  splint  to  the  one  used  in  hip  disease,  etc.  Fixa- 
tion can  be  discontinued  at  the  close  of  the  acute  stage,  but  pro- 
tection is  advisable  for  a  much  longer  time. 

Excision  is  not  an  advisable  method  of  treatment  until  mechani- 
cal measures  have  proved  inef-ficient  after  a  faithful  trial,  and  the 
same  is  true  of  arthrectomy.  Deformities  should  be  corrected  as 
they  arise. 


CHAPTER    IX. 

OTHER   DISEASES   OF   THE    KNEE-JOINT. 

Chronic  Synovitis.' — Intermittent  Hydrops  Articulorum. — Arthritis  Deformans. — Loose 
Bodies  in  the  Knee-joint. — Internal  Derangement  of  the  Knee-joint. — Bursitis. — 
Cysts  about  the  Knee-joint. — Charcot's  Disease. — Dislocation  of  the  Patella. — Pri- 
mary Disease  of  the  Cartilages. — Rupture  of  the  Patella  Tendon. 

Chronic  Synovitis. 

Simple  chronic  serous  synovitis  is  most  often  the  sequel  of  the 
acute  or  subacute  form.  It  may  be  also  idiopathic  in  origin,  or 
possibly  result  from  exposure  to  wet  or  cold.  It  occurs  at  any 
age,  either  in  children  or  adults.  When  it  is  the  outcome  of  acute 
synovitis,  the  chief  symptoms  of  that  affection  gradually  subside, 
leaving,  however,  a  joint  partly  full  of  fluid  and  disabled  on  that 
account.  A  recurrent  subacute  or  chronic  synovitis  also  results 
from  the  irritation  caused  by  loose  bodies  in  the  joints,  by  dis- 
placement of  the  cartilages,  and  by  slipping  of  the  patella.  These 
should  not  be  overlooked  in  assigning  a  cause  for  any  given  case. 
Pain  is  a  varying  quantity,  but  rarely  assumes  any  prominence, 
When  the  affection  does  not  originate  in  an  acute  attack,  the 
earliest  symptoms  are,  usually,  impaired  motion  and  pain  with 
slight  limp,  and  occasionally,  a  loss  of  strength  is  complained  of. 
The  pain  is  not  severe  unless  the  joint  is  excessively  used,  and  it  is 
relieved  by  rest.  Later,  swelling,  increased  surface  temperature, 
and  redness  of  the  skin  appear.  Tenderness  may  not  be  marked, 
except  in  the  acute  stages,  and  is  usually  most  marked  over  the 
internal  condyle.  If  neglected,  acute  inflammation,  even  of  a  puru- 
lent type,  may  result,  and  there  may  be  moderate  muscular  atrophy. 
After  a  time,  in  some  cases,  the  swelling  slowly  disappears  with  the 
absorption  of  the  effusion ;  the  patient  no  longer  has  pain  or  ten- 
derness, and  the  mobility  of  the  joint  is  restored.  In  many  patients 
this  recovery  is  not  permanent,  for,  after  a  period  of  weeks  or 
months,  a  recurrence  of  the  attack  occurs,  and  ultimate  recovery 
only  follows  after  several  such  exacerbations.  Generally,  where  no 
constitutional  tendency  to  disease  exists  to  change  the  character 
of  the  affection,  the  joint  finally  becomes  normal. 


OTHER   D/SKASF.S   OF    Till':   KM'lli-JOfNT. 


399 


Chronic  synovitis  presents  itself  in  various  forms.  There  mayor 
may  not  be  effusion  ;  the  effusion  may  be  serous,  sero-purulent,  or 
completely  purulent,  according  to  the  violence  of  the  affection. 
Chronic  tuberculous  synovitis  of  the  knee-joint  has  been  considered 
at  length  in  the  preceding  chapter.  Synovitis  of  the  knee-joint 
may  remain  indefinitely  in  a  subacute  condition,  with  a  slight  amount 
of  effusion,  accompanied  by  thickening  of  the  synovial  membrane, 


■fe" 


M 


i 


M 


i<¥ 


ill 


1 


'■1 


\        m 

Fig.  360. — Serous  Synovitis  of  tlie  Knee. 
Side  view.     (Schreiber.) 


Fig.  361. — Chronic  Serous  Synovitis  of  the  Knee. 
Front  view.     (Schreiber.) 


which  sometimes  is  gelatinous  in  appearance,  or  a  large  amount  of 
serous  effusion  may  take  place,  with  slight  inflammatory  symptoms. 
Hydrops. — The  type  of  synovitis  known  as  hydrops  articuli  differs 
clinically  from  the  ordinary  type  of  synovitis  inasmuch  as  there  is 
rarely  any  pain ;  the  symptoms  may  develop  gradually,  there  being 
no  complaint  except  a  slight  one  hardly  noticeable,  of  loss  of 
strength.  The  characteristic  effusion  gradually  develops,  and  dis- 
appears, or  remains  for  a  long  time  unchanged.     Sometimes,  how- 


400 


OR  TH  OPEDIC  S  UR  GER  V. 


ever,  the  effusion  appears  without  premonition  and  disappears 
equally  rapidly.  Muscular  atrophy,  impairment  of  motion,  pain  or 
tenderness,  may  all  be  absent,  there  being  no  evidence  of  trouble 
except  the  effusion  in  the  joint. 

Long-continued  chronic  synovitis  of  the  knee,  or  a  repetition  of 
acute  attacks,  leads  in  time  to  a  relaxed  condition  of  the  knee- 
joint.  Lateral  mobility  becomes  evident  and  the  muscles  fail  to 
control   the    joint   with   their    former    accuracy.     It   is   this   result 

which  is  more  to 'be  feared  than  per- 
manent stiffness  in  long-continued 
chronic  serous  synovitis.  In  uncom- 
plicated serous  synovitis  muscular 
spasm  is  not  present. 

Diagnosis. — The  diagnosis  of  the 
affection  is  made  by  the  recognition 
of  the  presence  of  fluid  in  the  joint. 
Dry  synovitis  is  rare  and  exceedingly 
difficult  to  recognize;  its  presence 
can  generally  be  determined  only  by 
the  exclusion  of  all  other  affections. 
Chronic  synovitis  with  effusion  is  evi- 
denced by  the  enlargement  of  the 
joint  and  the  fact  that  in  the  knee  the 
patella  is  lifted  by  the  effusion,  and 
floats.  In  examination  for  this  the 
fingers  of  both  hands  should  encircle 
the  limb  firmly  in  front,  above  and 
below  the  patella,  thus  confining  the 
effusion  to  the  space  directly  under 
the  patella  and  over  the  intercondy- 
loid  depression  on  the  femur.  The 
forefinger    of    one  hand   then   lightly 

Fig.  362.— Section  of  the  Knee-joint  in  a  Case     but     sliarply    prCSSeS     OD     the      patella, 
of  Chronic  Serous  Synovitis.     (Schreiber.i  i   .    1  1  r    1,    ,  1  1  1     1   •, 

which  can  be  telt  to  descend  and  hit 
the  femur.  This  matter  of  fully  extending  the  leg  and  grasping  it 
is  of  much  importance,  as  otherwise  a  small  effusion  may  escape 
detection.  At  other  times  pressure  over  the  lateral  and  anterior 
aspects  of  the  joint  will  confine  a  small  effusion  directly  under  the 
patella  so  that  it  floats  only  under  these  conditions. 

As  a  rule,  heat  and  tenderness  are  absent,  and  muscular  fixation 
may  be  present  or  absent,  but  it  is  not  a  frequent  symptom  of 
chronic  serous  synovitis.  The  affection  most  likely  to  be  mistaken 
for  chronic  serous  synovitis  is  chronic  inflammation  of  the  pre- 
patellar bursa,  "housemaid's  knee."     Here,  however,  the  swelling 


OTHl'lR    niSh'.ASI'lS    ()/■•    77f/<:   KNh'.hl-jniNT.  401 

is  local  and  clearly  in  front  of  llu;  patella,  instead  of  being  behind 
it;  it  is  ordinarily  seen  in  patients  who  Icneel  inucli  at  their  occu- 
pation, and  its  existence  does  not  linn't  the  motion  of  the  joint. 

Chronic  tumor  albus  beginning  as  an  epijihysitis  cannot  always 
be  differentiated  from  chronic  serous  synovitis. 

Hysterical  joint  disease  is  often  located  in  the  knee,  and  in  its 
symptoms  may  simulate  chronic  synovitis  very  closely;  but  objec- 
tive signs  are  absent.  There  is  no  swelling,  although  there  may  be 
tenderness,  and  thr;  v/hole  aspect  of  the  affection  is  much  more  like 
ostitis  than  synovitis  in  its  symptoms  of  local  tenderness  and  severe 
spasmodic  pain. 

Chronic  synovitis  is  always  slow  in  its  course,  and  the  tendency 
to  recurrence  is  very  great  in  certain  cases.  The  affection  shows 
so  great  a  tendency  to  run  on  into  tumor  albus,  especially  in  the 
case  of  children  of  poor  constitutional  inheritance,  that  the  prog- 
nosis should  be  guarded  and  the  suspicions  of  the  surgeon  easily 
aroused  by  any  tendency  toward  the  development  of  heat,  tender- 
ness, and  muscular  fixation. 

Treatment. — In  chronic  synovitis  without  effusion,  thorough  fixa- 
tion is  needed  in  the  early  or  more  acute  stages,  with  or  without 
compression. 

In  chronic  synovitis  with  serous  effusion  the  treatment  is  primar- 
ily to  cause  the  absorption  of  the  fluid  by  the  means  of  compression 
and  fixation.  Compression  is  most  readily  applied  to  a  knee-joint 
by  means  of  a  thin  rubber  bandage — -Martin's  bandage — wound 
about  the  limb;  bandages  of  elastic  cloth  can  also  be  used,  but  are 
not  as  efficient.  Dried  and  compressed  sponge,  bandaged  firmly 
about  the  limb,  will  expand  wdien  wet,  and  in  this  way  compress 
the  tissues  of  the  joint  effectively;  or  the  knee  may  be  thickly 
covered  with  sheet  wadding  and  binders'  board  made  pliable  by 
immersion  in  hot  water,  and  the  whole  bandaged  firmly. 

Inunction  of  fats,  of  oleates,  and  of  medicaments,  as  well  as 
painting  with  iodine,  etc.,  are  remedies  frequently  used,  but  their 
value  is  questionable.     The  same  may  be  said  of  cauterization. 

When  the  affection  is  accompanied  by  acute  symptoms,  the  ap- 
plication of  cold  by  ice-bags,  evaporating  lotions,  cold  douches,  or 
the  cold  coil  will  often  be  a  help,  and  in  some  instances  hot  cloths 
or  poultices  relieve  pain. 

Besides  this,  distraction  and  protection — one  or  both — are  needed 
if  there  is  danger  of  extension  of  the  disease  to  the  bone  or  cartilage; 
and  fixation  if  there  is  any  activity  of  disease.  The  use  of  mas- 
sage and  passive  motion  in  the  later  stages,  or  of  fixation  is  a  ques- 
tion of  judgment  in  each  individual  case,  it  being  borne  in  mind 
that  motion  is  a  normal  function  of  a  joint,  and  that  massage  may 
26 


402 


OR  THOPEDIC  S  URGER  Y. 


be  supposed,  by  temporarily  improving  the  local  circulation,  to 
promote  the  absorption  of  synovial  oedema  or  its  results,  and,  on 
the  other  hand,  that  anything  which  increases  the  inflammation  in 
a  joint,  like  ill-judged  motion,  is  an  injury. 

When  the  inflammatory  stage  is  passed  and  there  is  no  further 
danger  of  extension  of  the  disease  to  the  bones  or  cartilage,  mas- 
sage, as  well  as  passive  exercises,  may  be  allowed.  Twists  and  sud- 
den jars  are  to  be  avoided,  and  protection  (crutches  or  splints)  is 
advisable  in  the  stage  of  convalescence  if  the  attack  has  been  at 
all  a  severe  or  a  protracted  one. 

In'  general  the  type  of  chronic  serous  synovitis  is  well  marked 
and  presents  no  indication  for  protection  or  traction,  but  simply 
for  fixation  and  compression. 

In  the  form  of  synovitis  known  as  hydrops  articuli  (water  on  the 
knee)  the  treatment  is  such  as  would  promote  absorption  or  re- 
moval of  the  fluid.  Besides  friction  and  compression,  which  are 
often  sufficient,  aspiration  is  of  great  service.  The  procedure  may 
be  considered  as  free  from  danger.  The  best  method  of  applying; 
is  as  follows:  After  thoroughly  cleansing  the  skin,  the  knee  is  band- 
aged with  rubber  to  exert  slight  pressure,  leaving  a  small  portion 
of  the  knee  uncovered  for  the  insertion  of  the  aspirating  needle. 
This  is  best  done  at  a  little  distance  from  the  side  of  the  patella. 
The  size  of  the  needle  should  depend  upon  the  character  of  the 
fluid ;  if  thorough  asepsis  is  carried  out  a  needle  of  large  size  or  a 
trocar  is  free  from  danger.  After  the  joint  has  been  aspirated,  the 
wound  should  be  covered  with  a  piece  of  aseptic  gauze  or  cotton 
and  a  rubber  bandage  applied  over  the  knee.  If  the  fluid  is  again 
effused,  the  joint  can  again  be  aspirated. 

When  reproduction  of  fluid  takes  place,  injection  of  iodine,  as  in 
the  treatment  of  hydrocele,  has  been  recommended  and  used,  but 
sometimes  the  results  have  been  disastrous. 

Antiseptic  irrigation  of  the  joint  has  of  late  been  advocated  as 
a  cure  for  chronic  synovitis  of  the  knee-joint.  On  account  of  the 
great  resistance  which  many  cases  of  the  affection  offer  to  the  ordi- 
nary methods  of  treatment,  one  turns  readily  to  any  means  of  re- 
lief which  may  be  tried  when  the  methods  by  compression,  etc., 
have  failed.  A  large  proportion  of  the  fluid  in  the  joint  is  with- 
drawn by  aspiration  and  its  place  partly  filled  by  the  injection  of 
a  few  ounces  of  either  five-per-cent  carbolic-acid  solution,  or  i  :  5,000 
corrosive  sublimate  ;  the  latter  is  probably  attended  with  less  risk, 
and  in  Germany  its  use  has  superseded  that  of  carbolic  acid.  Many 
very  successful  cases  have  been  reported,  where,  after  the  use  of 
this  method,  the  joint  has  been  kept  quiet  and  the  fluid  has  never 
returned. 


otiii-:r  d/sjcases  a/'-  77//-:  i<\i:e-J()Ini\ 


403 


Cases  of  intermittent  hydrops  articulorum  of  one  or  both  knees, 
(which  occurred  in  apparently  healthy  patients)  are  reported  by 
Seeligmuller  and  Nicolaysen.'  The  symptoms  recurred  at  regular 
intervals  and  in  some  cases  yielded  to  treatment  for  malaria. 


/    -1  w 


Arthritis  Deformans. 

The  knee  is  one  of  the  large  joints  most  frequently  attacked  by 
arthritis  deformans,  or  rheumatoid  arthritis. 

Symptoms. — Pain  and  stiffness  are  the  symptoms  at  first  com- 
plained of.  Pain  may  involve  the  whole  joint,  but  is  more  com- 
monly localized  in  a  tender  spot  over  the  internal  condyle  of  the 
femur,  vlt  varies  very  much  in  amount;  and 
is  likely  to  increase  in  intensity  in  conse- 
quence of  exposure  to  cold  or  wet,  and  when 
the  weather  becomes  cold  and  raw,  or  when 
some  indiscretion  m  diet  has  been  committed, 
and  as  a  result  of  over-use  of  the  affected  leg. 
At  the  beginning  of  nearly  all  cases,  pain 
occurs  in  acute  attacks  accompanied  by  local 
heat,  with  much  tenderness,  and  swelling. 
The  acute  symptoms  subside,  to  return  again 
and  again,  leaving  behind  them  each  time 
a  certain  amount  of  structural  change  in  the 
joint  in  the  form  of  synovial  thickening,  bony 
enlargement,  and  peri-articular  infiltration. 

At  first  the  swelling  may  be  due  to  synovial  effusion  which  marks 
the  beginning  of  the  affection  in  many  cases ;  in  other  instances 
synovial  distention  does  not  occur.  Ultimately  the  outline  of  the 
joint  becomes  indistinct  and  a  boggy  or  hard  swelling  envelops  the 
knee.  The  character  of  the  pathological  change  can  be  seen  in  the 
figure  (363).  Stiffness  at  first  passes  off  with  movement,  but  later  in 
the  disease  it  becomes  permanent,  often  to  the  point  of  ankylosis. 
Creaking  in  the  diseased  joint  is  an  early  and  characteristic  symp- 
tom and  reveals  only  too  plainly  the  nature  of  the  affection. 

The  phenomenon  is  due  to  calcification  and  erosion  of  the  artic- 
ular cartilage,  or  to  the  formation  of  rough  cartilaginous  nodules  in 
the  synovial  fringes,  which  are  rubbed  together  when  the  joint  is 
moved.  It  is  also  probable  that  the  same  sensation  can  be  pro- 
duced without  any  structural  change  by  mere  dryness  of  the  artic- 
ular surfaces ;  for  grating  is  not  uncommon  in  the  functional  affec- 
tions of  the  knee  classed  as  hysterical. 

In  general,  the  tendency  of  the  affection  is  toward  greater  and 

'Cent.  f.  Chir.,  Oct.  15th,  1887. 


Fig.  363. 


404 


ORTHOPEDIC  SURGERY. 


greater  impairment  of  the  joint  motion,  with  wasting  of  the  mus- 
cles and  atrophy  of  the  skin,  so  tli-at  in  the  advanced  stages  one 
can  see  a  stretched  and  shining  skin  tightly  drawn  over  the  de- 
formed and  distorted  joint.  Most  commonly  the  affection  of  the 
knee-joint  is  associated  with  arthritis  deformans  of  the  joints  of 
the  upper  extremity. 

The  outlook  is  unfavorable,  unless  the  disease  is  taken  in  the  very 
earliest  stages;  not  that  life  is  likely  to  be  shortened,  but  that  vei-y 
serious  disability  of  the  joint  most  often  results. 

Treatment. — During  the  acute  attacks  above  alluded  to,  when 
pain  is  caused  by  walking  and  movement,  and  heat  and  tenderness 
are  present,  rest  is  very  strongly  indicated  along  with  counter-irri- 
tation, which  is  best  applied  in  the  form  of  blisters  over  the  joint 
or  tincture  of  iodine  painted  on  abundantly.  Hot-water  douches 
and  compression  by  a  rubber  bandage  or,  better  still,  by  a  Gamgee 
dressing  of  millboard  and  sheet  wadding,  are  also  of  much  benefit. 
A  few  days  will  suffice  to  quiet  the  acute  symptoms,  but  on  re- 
covery there  may  be  a  somewhat  greater  degree  of  stiffness  than 
there  was  before  the  attack.  This  is  to  be  expected  as  the  out- 
come of  each  attack.  During  this  quiescent  stage,  the  best  local 
measures  are  massage,  counter-irritation,  hot  douching,  and  pro- 
tection of  the  joint  by  a  warm  covering,  such  as  a  flannel  bandage; 
moderate  exercise  is  also  to  be  regarded  as  a  therapeutic  measure, 
when  it  is  not  attended  by  too  much  discomfort.  If  pain  is  exces- 
sive, one  has  to  face  the  dilemma  of  continuing  motion  which  is 
excessively  painful  or  of  allowing  the  patient  to  rest  and  keep  the 
joint  still,  by  which  process  one  is  likely  to  favor  the  stiffening  of 
the  joint,  if  it  is  continued  for  too  long  a  time.  For  short  periods, 
however,  there  is  no  risk,  and  sometimes  much  to  be  gained  by 
complete  rest  to  the  affected  articulation. 

Much  importance  in  the  matter  of  treatment  is  to  be  attached  to 
general  measures,  and  when  it  is  practicable,  nothing  is  likely  to  be 
of  greater  benefit  than  a  visit  to  some  well-chosen  health  resort. 
In  America,  the  Arkansas  Hot  Springs  and  Richfield  and  Sharon 
Springs  in  New  York  are  to  be  recommended ;  but  the  necessary 
regime  is  not  so  well  carried  out  as  in  the  foreign  watering  places, 
which  are  still  more  likely  to  be  of  benefit.  In  England  one  has 
Buxton,  Harrogate,  and  Droitwich,  which  are  suitable  to  this  affec- 
tion; and  on  the  continent  these  resorts  are  almost  without  num- 
ber, the  best  ones  being  Aix-les-Bains,  Carlsbad,  Baden,  Vichy, 
Wildbad,  and  Teplitz.  The  benefit  of  the  waters  and  baths  in  these 
places,  along  with  the  change  of  scene  and  a  carefully  regulated 
diet  and  regime,  often  accomplish  wonders. 

Such  a  measure  of  treatment,  however,  is  out  of  the  reach  of  the 


OTHER    D/S/wlSKS   ()/■     TJII'.    KN I-IK-JOI NT.  405 

majority  of  patients,  and  one  lias  t(j  consider  nuich  more  often  the 
method  whicli  is  likely  to  be  of  most  use  at  liome. 

The  diet  should  be  carefully  regulated;  meat  should  be  taken 
sparingly,  especially  red  meat  of  all  kinds,  and  the  preference  given 
to  game,  fish,  and  poultry;  vegetables  in  moderation;  ripe  fruit 
and  farinaceous  food  are  to  be  taken.  Milk  and  eggs  should  be 
taken  in  abundance  ;  each  day  the  patient  should  drink  a  stated 
amount  of  skimmed  milk,  which  should  be  as  large  a  quantity  as 
possible.     Alcohol  must  be  forbidden  and  sweets  avoided. 

Water,  which  will  act  as  a  diuretic,  should  be  taken  in  measured 
quantity  daily.  (From  one  to  two  quarts  at  least.)  IJthia  waters 
are  useful,  but  in  many  of  the  natural  waters  the  quantity  of  the 
drug  contained  is  so  small  that  it  is  better  to  resort  to  one  of  the 
artificial  waters  containing  a  large  amount  of  the  drug.  A  very 
useful  addition  to  the  water  taken  at  meals  is  a  teaspoonful  of  the 
imported  Vichy  salt,  or  of  one  of  the  artificially  prepared  efferves- 
cent Vichy  salts  sold  here. 

It  is  desirable  to  take  a  hot  bath  at  least  twice  each  week,  to 
promote  secretion  by  the  skin,  and  the  bowels  should  be  kept 
active  by  saline  laxatives.  General  and  local  massage  is  a  resource 
of  the  greatest  value,  and  a  mild  galvanic  current  is  also  of  much 
benefit  as  a  promoter  of  proper  circulation. 

Less  is  to  be  expected  in  the  matter  of  drugs  than  from  general 
hygiene  and  treatment. 

Salicin  or  salicylate  of  soda  in  ten-grain  doses,  three  times  daily, 
often  has  a  marked  effect  in  controlling  the  affection,  and  an  alka- 
line diuretic  is  almost  a  necessity.  Lithia,  or  the  salicylate  of  lithia, 
at  other  times  accomplishes  more  than  salicylic  acid  does.  Arsenic 
is  sometimes  useful  to  a  marked  degree,  but  iodide  of  potash  is  not 
generally  of  much  benefit.  Tonics  should  be  given  in  the  form  of 
iron  or  quinine,  or  strychnine,  if  the  general  condition  is  not  good 
or  if  the  appetite  fiags. 

When  ankylosis  of  the  knee  in  a  faulty  position  has  resulted  from 
rheumatoid  arthritis,  brisement  force  is  to  be  tried  for  its  rectifica- 
tion, as  described  for  the  correction  of  ankylosis  after  tumor  albus. 
It  is  not,  of  course,  to  be  expected  that  motion  will  be  present  in 
the  joint  in  its  new  position,  for  the  structural  changes  must  have 
already  been  extensive  to  have  induced  the  deforming  ankylosis. 
Excision  of  the  knee  may  be  required  in  cases  Avhich  are  so  firmly 
ankylosed  as  to  resist  the  surgeon's  attempt  at  straightening. 

When,  however,  the  ankylosis  is  the  outcome  of  a  simple  rheu- 
matic synovitis  occurring  in  the  course  of  an  acute  or  chronic  at- 
tack of  rheumatism,  forcible  manipulation  may  break  up  the  ad- 
hesions which  have  caused  the  joint  stiffness  and  restore  a  certain 


4o6  ORTHOPEDIC  SURGERY. 

amount  of  permanent  motion  to  the  articulation.  These  cases  are 
to  be  distinguished  from  the  ankylosis  of  arthritis  deformans  by  the 
fact,  that  in  the  former  the  joint  is  practically  normal  in  outline 
and  there  is  no  bony  enlargement  of  that  or  the  other  joints,  de- 
scribed as  a  characteristic  of  arthritis  deformans. 


Loose  Bodies  in  the  Knee-Joint. 

The  pathology  and  formation  of  loose  bodies  has  already  been 
considered  in  speaking  of  the  pathology  of  joint  disease.  It  re- 
mains here  to  speak  only  of  the  symptoms  caused  by  their  presence. 

It  has  been  stated  that  nine-tenths  of  all  the  cases  occur  in  the 
knee-joint.  In  a  majority  of  cases  the  first  intimation  to  the 
patient  that  anything  is  wrong  is  that  while  in  the  act  of  walk- 
ing or  stooping  he  is  seized  with  such  agonizing  pain  in  the 
knee  that  he  falls  to  the  ground,  in  many  cases  overcome  with  the 
sensation  of  faintness  and  sickening  pain.  At  times,  this  pain  sub- 
sides almost  immediately,  and  the  patient  is  able  to  walk  within  a 
few  minutes;  but  at  other  times  the  joint  remains  fixed  in  a  posi- 
tion of  more  or  less  flexion,  with,  perhaps,  outward  rotation  of  the 
tibia,  and  any  attempt  to  move  it  is  attended  with  very  severe  suf- 
fering. In  any  event,  such  an  occurrence  is  apt  to  be  followed  by 
an  attack  of  synovitis  lasting  several  days.  Up  to  this  time  the 
joint  has  very  likely  been  normal  and  given  no  trouble,  but  these 
attacks  are  likely  to  be  repeated  without  any  assignable  cause. 
On  manipulation  of  the  joint  with  the  fingers,  it  is  often  possible  to 
detect  a  loose  body  which  shifts  its  position  and  is  found  first  in 
one  part  of  the  joint  and  then  in  another.  The  most  common  spot 
where  they  can  be  detected  externally  is  in  the  pouch  over  the  ex- 
ternal or  internal  condyle  of  the  femur.  They  are  felt  as  smooth 
slippery  bodies  under  the  skin,  which  evade  the  fingers'  grasp  with 
surprising  readiness.  Occasionally  they  may  be  found  over  the 
tibia  inside  the  ligamentum  patellae,  and  when  one  of  these  sub- 
stances has  been  found  it  is  desirable  to  see  if  others  are  present  in 
the  joint.  Sometimes  it  is  impossible  to  detect  any  loose  bodies 
from  the  outside,  and  the  history  of  the  case  must  be  depended 
upon  to  establish  the  diagnosis.  In  some  cases  the  attacks  are  of 
very  frequent  occurrence,  while  in  others  it  is  only  at  intervals  of 
several  weeks  or  months  that  the  joint  gives  any  trouble. 

With  repetition  of  attacks  the  joint  becomes  more  tolerant  and 
the  synovitis  less  severe.  In  cases  where  arthritis  deformans  is 
present  as  the  cause  of  the  loose  bodies,  the  history  of  the  attacks 
is  less  typical.  The  patient,  however,  experiences  in  a  measure 
the  same  sudden  catching  of  the  joint,  and  movement  of  the  af- 


OTIIIZR   DISEASES   Ul''    THE   KN IlE-JOEMT.  407 

fcctccl  knee  is  painful,  restricted,  and   attended  with  a  particularly 
distinct  grating. 

Diagiiosic. — Finding  a  movable  body  which  can  be  sh'pped  from 
place  to  place  by  manipulation  establishes  the  diagnosis. 

In  cases  where  the  loose  body  cannot  be  found,  one  must  depend 
largely  upon  the  history  ;  making,  however,  frequent  examinations 
under  different  conditions  with  the  hope  of  ultimately  detecting 
the  foreign  body. 

The  diagnosis  between  internal  derangement  of  the  knee-joint 
and  a  loose  cartilage  is  often  a  difficult  one  to  make,  and  dependence 
must  be  placed  chiefly  upon  tenderness  in  a  very  small  spot  over 
the  head  of  the  tibia  as  establishing  the  probable  occurrence  of 
dislocation  of  one  of  the  semilunar  cartilages.  In  the  majority  of 
cases  of  loose  bodies,  on  the  other  hand,  it  is  possible  to  ultimately 
detect  externally  their  presence,  as  causing  the  trouble. 

Treatment. —  In  cases  where  the  loose  body  gives  but  little  incon- 
venience and  is  kept  from  passing  between  the  ends  of  the  bone 
by  a  knee  cap  it  is  not  advisable  to  undertake  operative  treatment. 
In  other  cases,  especially  in  arthritis  deformans,  the  joint  may  have 
become  so  much  impaired  by  the  disease  that  even  if  a  foreign 
body  were  removed  little  would  be  gained.  In  the  great  majority 
of  cases,  however,  inasmuch  as  the  disease  occurs  in  otherwise 
healthy  persons,  mostly  young  adults,  any  operation  which  does 
not  entail  serious  risk  is  advisable.  Before  the  advent  of  antisep- 
tic surgery  interference  with  these  bodies  was  a  most  serious  matter, 
since  it  necessitated  opening  the  joint,  and  various  expedients 
were  undertaken  to  introduce  them  into  the  peri-articular  tissue 
and  so  get  them  out  of  the  joint  without  cutting  the  skin.  Such 
an  operation,  however,  has  become  obsolete.  In  the  report  of  the 
Society  of  Surgery  in  Paris,  Larrey  gave  as  a  result  of  131  opera- 
tions by  direct  incision,  98  recoveries  and  28  deaths;  21.3  per 
cent.  Where,  however,  the  indirect  method  (in  which  the  capsule 
is  opened  subcutaneously)  was  employed,  in  39  operations  only  5 
deaths  occurred,  12.8  per  cent. 

Bar  well,  reporting  88  cases  operated  upon  from  i860  to  1884 
(necessarily  including  many  septic  operations)  gives,  as  a  result 
of  48  direct  operations,  44  recoveries  and  4  deaths  which  is  8,3 
per  cent  deaths.  Woodward,  in  a  very  admirable  article  from 
which  these  figures  have  been  taken,  was  only  able  to  find  a  very 
few  reported  cases  which  had  been  operated  upon  by  the  indirect 
method  since  1874.  He  was  able,  on  the  other  hand,  to  collect  105 
cases  where  a  direct  antiseptic  incision  of  a  joint  had  been  made 
for  the  removal  of  a  foreign  body.  In  104  of  these  the  knee  was 
the  joint    affected,  and  92    of  these  were  for  the  removal  of  loose 


4o8  ORTHOPEDIC  SURGERY. 

cartilages.  In  one  case  the  foreign  body  proved  to  be  a  sarcoma^ 
in  one  a  fibroma,  and  in  one  a  lipoma.  In  two  cases  nothing  could 
be  found,  and  in  one  of  these,  adhesions  behind  the  back  of  the 
patella  were  forcibly  broken  up.  There  was  but  one  death  in  these 
105  operations,  and  that  was  due  to  phlegmonous  erysipelas,  so 
that  the  asepsis  of  this  operation  is,  at  least,  doubtful.  The  same 
may  be  said  of  two  other  cases  where  suppuration  necessitated 
amputation  of  the  thigh,  while  stiffness  of  the  affected  joint  re- 
sulted in  three  cases ;  in  one  of  which  400  loose  cartilages  had  been 
removed,  in  another  24  and  in  a  third  4.  In  4  other  cases  besides 
these,  slight  impairment  of  motion  was  reported. 

In  place,  therefore,  of  Larrey's  death  rate  of  21.3  per  cent 
and  Barwell's  death  rate  of  8.3  per  cent,  the  death  rate  of  the 
cases  reported  by  Woodward  is  less  than  i  per  cent,  with  much 
doubt  to  be  attached  to  the  asepsis  of  the  operation  in  which  the 
death  occurred. 

It  seems,  therefore,  as  if  the  risk  of  this  operation,  both  as  to  life 
and  function  of  the  limb,  was  so  slight  as  to  be  disregarded  in  the 
choice  of  an  operation.  In  complicated  cases,  of  course,  there  is  a 
possibility  of  more  or  less  resulting  stiffness.  The  list  of  105  cases 
is  given  in  full  in  Woodward's  paper  (^Boston  Med.  and  Surg.  Jour- 
nal, April  25th,  1889).     The  operation  is  performed  as  follows: 

The  loose  body  having  been  found,  a  needle  is  passed  through  it 
from  the  outside  to  steady  it,  and  it  is  then  cut  down  upon  by 
careful  dissection  until  it  is  exposed  and  removed.  After  the  re- 
moval of  the  body  originally  detected,  the  joint  should  be  carefully 
examined  to  see  if  others  are  present.  Although  in  general  it  would 
not  be  deemed  advisable  to  cut  down  upon  a  joint  where  the  pres- 
ence of  loose  bodies  was  suspected,  yet  in  a  case  where  continual 
trouble  was  caused,  an  exploratory  incision  into  the  knee-joint 
would  be  attended  with  very  slight  risk  and  might  be  of  very  great 
benefit  in  discovering  the  presence  of  pedunculated  loose  bodies 
which  escaped  detection  from  the  outside.  There  is,  of  course,  a 
slight  tendency  to  the  re-formation  of  these  bodies  after  one  or 
more  have  been  removed. 

With  regard  to  the  treatment  of  the  synovitis  which  is  caused  by 
the  "  catching  "  of  the  limb,  a  few  days'  rest  will  be  sufificient  to 
quiet  it.  The  patient  soon  acquires  the  habit  of  straightening  the 
limb  himself,  after  the  attack,  when  it  is  fixed  in  a  flexed  position. 

Internal  Derangement  of  the  Knee-Joint. 

The  term  "  internal  derangement  "  had  its  origin  in  a  classical 
paper  written  by  Hey  in  the  year  1803.  The  name  is  appropriate, 
since  it  Involves  no  etiological  theory.     Hey  described  the  condi- 


OTHER   DISEASES   OJ'     Tllh:   KNl-.l'.-JO/NT.  409 

tion  as  follows:  "  Though  so  firmly  supported  by  tcndfjns  and  lig- 
aments, the  knee-joint  is  not  infrequently  affected  with  some  inter- 
nal derangement  of  its  component  parts,  sometimes  in  consequence 
of  trifling  accidents.  In  cases  not  attended  with  contusion,  the 
joint  in  respect  to  its, shape  appears  not  injured;  at  most,  the  liga- 
mentum  patellar  appears  rather  more  relaxed  than  in  the  sound 
limb;  the  leg  is  readily  bent  or  extended  by  the  hands  of  the  sur- 
geon without  pain  to  the  patient.  At  most  the  signs  of  uneasiness 
caused  by  these  flexions  and  extensions  are  slight,  but  the  patient 
himself  cannot  freely  bend  or  extend  the  limb  in  walking,  he  is 
compelled  to  walk  with  invariably  a  small  degree  of  flexion  ;  though 
the  patient  is  obliged  to  keep  the  leg  stiff  in  walking  yet  in  sitting 
down  the  affected  joint'will  move  like  the  other." 

Hey  believed  the  cause  of  the  complaint  to  be  brought  about  by 
some  change  which  prevents  the  condyle  of  the  femur  from  moving 
freely  in  the  hollow  formed  by  the  semilunar  cartilages  and  the 
articular  depressions  of  the  tibia.  The  unequal  tension  of  the  lat- 
eral or  cross  ligaments  of  the  joint,  or  some  slight  derangement  of 
the  semilunar  cartilage,  may  probably  be  sufficient  to  bring  on  the 
complaint;  but  the  condition  seems  to  have  its'origin  in  the  relax- 
ation of  the  attachment  of  the  articular  cartilage,  or  in  the  tearing 
away  of  the  cartilage  from  its  connection  by  some  injury. 

The  symptoms  are  in  a  measure  similar  to  those  described  under 
loose  cartilage.  The  patient  by  some  violent  muscular  effort,  as  in 
kicking  foot-ball  or  falling  from  a  horse  or  carriage,  wrenches  the 
knee  and  finds  it  impossible  to  fully  extend  it,  and  walks  with  it 
bent  in  the  way  described,  suffering  much  pain. 

In  some  instances,  as  in  the  case  related  by  Mr.  White  {Lan- 
cet, vol.  i.,  page  11,  1856),  much  tenderness  could  be  found  over 
the  inner  tuberosity  of  the  tibia  where  none  was  present  over  the 
outer  tuberosity;  and  Mr.  Marsh  photographed  a  case  which  shows 
externally  a  depression  over  the  situation  of  the  internal  semi- 
lunar cartilage.  This  sudden  locking  of  the  joint  as  far  as  exten- 
sion is  concerned,  is  almost  the  only  characteristic  symptom  of 
internal  derangement;  but,  as  has  been  said,  occasionally  on  exam- 
ination one  finds  a  depression  or  a  protrusion  of  one  of  the  semi- 
lunar cartilages.  This  establishes  the  diagnosis,  and  a  sharp  attack 
of  synovitis  of  course  follows  such  a  severe  injury  to  the  joint. 

The  most  marked  cases  happen  after  some  serious  wrench  to  the 
joint.  Nevertheless,  marked  cases  occur  in  which  the  cartilage  is, 
perhaps,  only  relaxed,  and  in  these  a  much  less  painful  locking  of 
the  joint  arises.  The  affection  is  masked  in  many  patients  by  the 
severity  of  the  acute  synovitis  which  follows  the  injur}',  and  the 
true  character  of  the  accident  may  not  be  learned  for  a  long  time 


410 


OR  THOPEDIC  S  URGER  Y. 


afterward  unless  its  history  is  most  carefully  inquired  into,  and  this 
of  course  is  a  serious  matter.  One  occurrence  of  the  accident  pre- 
disposes to  subsequent  attacks.  The  larger  group  of  cases  would 
be  better  designated  as  dislocations  of  the  internal  semilunar  car- 
tilage, which  affection  has  become  more  common  since  the  prev- 
alence of  lawn  tennis  as  a  sport,  but  still  it  is  a  decided  rarity  in 
common  surgical  practice.  Nicoladoni  has  reported  a  case  of  this 
unusual  affection,  which,  he  says,  is  frequently  confounded  with  a 
loose  cartilage.  Observations  are  on  record  where  the  meniscus 
could  be  readily  felt  as  dislocated,  and  where,  after  reduction,  the 
symptoms  disappeared.  In  this  case  (in  which  the  symptoms  fol- 
lowed an  accident  in  the  gymnasium)  the  joint  was  cut  down  on 
in  the  expectation  of  removal  of  a  loose'  cartilage,  when  it  was 
discovered  that  the  semilunar  cartilage  caused  the  difificulty,  and 
the  synovial  membrane  was  stitched  together  in  the  hope  that 
the  contraction  of  cicatrization  would  fix  the  cartilage.  This  did 
not  take  place,  and  the  patient,  after  a  ready  recovery  from  the 
operation,  was  in  no  way  better  of  his  previous  symptoms.  On 
a  dissecting-room  cadaver  a  similar  lesion  was  found,  which  on 
investigation  was  found  to  be  a  loosened  and  altered  semilunar 
cartilage. 

Jersey'  is  of  the  opinion  that  the  injury  which  is  called  the  rup- 
ture of  the  internal  lateral  ligament  of  the  knee  is  in  reality  a  sepa- 
ration of  the  tuberosity  of  the  internal  condyle  of  the  femur.  As 
a  support  of  this  view,  he  quotes  the  results  of  experiments  on 
cadavera  as  follows :  in  three  adult  cadavera  a  separation  of  the 
tuberosity,  and  in  two  young  cadavera  a  separation  of  the  epiphy- 
sis of  the  tibia,  followed  forcible  turning  the  leg  out,  the  femur 
being  held  firmly. 

Internal  derangement  of  the  knee  joint  affects,  for  the  most  part, 
persons  between  20  and  50  years  of  age  and  occasionally  occurs  in 
children. 

The  treatment  of  the  affection  is,  first,  the  reduction  of  the  de- 
formity at  the  time  of  the  accident ;  and,  second,  the  prevention  of 
its  repetition.  Patients  who  are  liable  to  the  displacement  soon 
learn  the  manipulation  themselves.  In  the  first  instance  the  in- 
jured person  is  very  often  at  a  loss  how  to  proceed,  but  straighten- 
ing the  leg  is  very  simple.  The  knee  should  be  bent  to  its  fullest 
extent,  the  tibia  should  then  be  drawn  away  from  the  femur  as  far 
as  possible,  to  separate  the  joint  surfaces,  at  the  same  time  rotat- 
ing the  tibia  inward  and  outward,  and  then  the  leg  should  be  ex- 
tended quickly  but  not  forcibly  to  its  fullest  extent,  while  the  sur- 
geon manipulates  with  the  thumb  the  situation  of  the  semilunar 
^  N.  Y.  Med.  Record,  June,  18S1,  p.  663. 


OTHER    D/S/wlSKS    ()/''    Tin:   KNI'JC-JOfNT.  411 

cartilages,  especially  if  any  undue  prominence  slioiilrl  he  felt.  An 
ancX'sthetic  is  very  often  necessary  and  advisable.  The  reduction  in 
exceptional  instances  cannot  be  effected,  but  commonly,  and  espe- 
cially with  the  use  of  an  an;esthetic,  reduction  takes  place  easily 
and  a  distinct  click  is  heard  in  many  cases.  The  leg  should  then 
be  put  at  perfect  rest  and  the  treatment  for  synovitis  instituted. 

Secondly,  with  regard  to  the  recurrence  of  the  displacement  of 
the  cartilage.  In  many  cases  where  the  joint  is  sound  and  the  car- 
tilage displaced  without  being  lacerated  to  any  extent,  its  disloca- 
tion will  probably  never  occur  again.  When,  however,  the  carti- 
lage is  much  drawn  or  its  attachments  are  much  relaxed  it  is  liable 
to  be  very  troublesome  by  slipping  from  time  to  time,  causing  this 
acute  locking  of  the  joint. 

For  the  purpose  of  retaining  the  cartilage  in  its  position  some 
mechanical  appliance  is  necessary,  and  a  very  admirable  knee-cap 
has  been  invented  by  Mr.  Marsh,  which  consists  of  two  closely  fit- 
ting plates  of  steel  which  clasp  the  joint  at  each  side  of  the  patella 
and  are  fastened  together  around  the  back  of  the  joint  by  a  tight 
band. 

In  other  cases  a  modification  of  this  may  be  necessary,  extending 
up  and  down  the  leg  for  a  short  distance ;  and  often  the  wearing  of 
this  appliance  may  be  dispensed  with  after  a  few  months  when  the 
torn  structures  are  firmly  healed ;  but  where  the  laceration  is  very 
extensive  some  such  knee  clamp  may  have  to  be  worn  perma- 
nently. 

Bursitis  of  the  Knee. 

This  affection,  known  as  "  housemaid's  knee,"  is  found  chiefly  in 
persons  whose  occupation  leads  them  to  spend  much  time  in  kneel- 
ing. The  bursa  affected  in  a  great  majority  of  cases  is  the  bursa 
patellee,  which  lies  over  the  patella  and  part  of  the  ligamentum 
patellae,  and  generally  has  no  connection  with  the  joint.  The  acute 
affection  is  brought  about  by  over-use  of  the  knee  and  is  charac- 
terized by  slight  swelling,  sensitiveness  on  pressure,  and  discomfort 
in  flexing  the  knee,  which  is  localized  at  the  site  of  the  bursa. 
Palpation  shows  a  more  or  less  distinct  swelling,  which  lies  over  the 
patella  and  which  is  rendered  more  tense  by  the  flexion  of  the 
joint.  In  the  acute  stage  it  is  likely  to  be  mistaken  for  synovitis 
of  the  knee-joint,  especially  as  the  inflammation,  if  neglected,  tends 
to  spread  and  the  swelling  becomes  more  diffuse  and  burrows 
around  the  joint ;  although  the  chronic  enlargement  of  the  bursa  is 
sometimes  primary,  more  often  it  is  the  outcome  of  a  series  of 
acute  attacks.  The  amount  of  swelling  is  greater,  and  flexion  is 
clearly  present,  but  the  swelling  is  more  sharply  localized  to  the 


412 


ORTHOPEDIC  SURGERY. 


region  in  front  of  the  patella  than  in  synovitis.  In  the  chronic 
stage  of  the  affection,  heat,  sensitiveness,  and  discomfort  are  ordi- 
narily absent,  except  a  slight  feeling  of  stiffness  in  complete  flexion 
of  the  leg. 

There  is  a  deeper  bursa  at  the  knee-joint,  which  is  sometimes  the 
seat  of  inflammation,  especially  in  the  case  of  young  adolescents. 
It  lies  between  the  ligamentum  patellae  and  the  anterior  surface  of 
the  tibia.     It   causes  a  dull  pain  below  the  joint  made  Avorse  by 

exercise,  and  local  tenderness  is  present  just 
above  the  tuberosity  of  the  tibia,  which 
may  appear  enlarged.  In  any  event,  swell- 
ing is  likely  to  be  present  just  above  it,  so 
much  sometimes,  that  the  condition  closely 
simulates  ostitis  of  the  head  of  the  tibia. 

The  chronic  bursitis,  as  well  as  the  acute 
affection  of  the  superficial  bursa,  presents 
a  decided  resemblance  to  chronic  synovi- 
tis,  and   for  diagnosis,   one    must    depend 
upon  the  facts  that  the  swelling  is  entirely 
in  front  of  the  patella,  that  the  patella  does 
not  float,  that  the  joint  is  not  affected,  and 
that  the  occupation  of  the  patient  in  some 
way  has  produced  continual  slight  injuries 
of  this  region.     Although  the  acute  affec- 
r^   tion  shows   a    tendency  toward    recovery 
,';  -  under  rest,  the  chronic  affection  does  not 
^^^  have  this  tendency  and  is  likely  to   con- 
tinue unabated. 

Suppuration  occurs  in  both  acute  and 
chronic  varieties  in  a  certain  proportion  of 
cases;  and  it  is  generally  in  consequence  of  som.e  depleted  con- 
dition of  the  system  or  some  local  aggravation.  The  inflammation 
of  the  bursa  occasionally  occurs  in  connection  with  gout,  rheuma- 
tism, or  syphilis. 

At  times  the  bursae  become  distended  in  consequence  of  an  effu- 
sion into  the  joint.  This  is  not  the  case  with  the  bursa  patellae, 
which  is  entirely  shut  off  from  the  knee,  but  the  bursa  under  the 
semi-membranosus  in  the  popliteal  space  occasionally  enlarges, 
when  fluid  collects  in  the  joint,  and  in  this  case  fluctuation  between 
the  joint  and  the  bursa  may  be  clearly  felt. 

Treatment. — As  to  modes  of  treatment,  the  acute  affection,  unless 
too  far  advanced,  ordinarily  yields  readily  when  the  limb  is  placed 
in  the  extended  position  upon  a  ham  splint,  and  the  constant  irrita- 
tion of  walking-  is  avoided.      Paintiner  the  skin  with  iodine  and  the 


Bursitis  of  the  Knee. 


OTHER   J)/S/':ASJ':S   ()/■     Till':  KNh.h.-jOINi:  4J3 

application  of  pressure  cither  by  slieet  vvuddin^r  and  bandages,  or 
by  an  elastic  flannel  bandage,  are  of  nuicli  assistance  in  allaying  tiic 
inflammation;  a  few  days  or  weeks  in  the  mihler  cases  will  ordi- 
narily reduce  the  inflammation.  In  old  cases  this  treatment  has 
little  or  no  effect.  If,  however,  the  bursitis  has  reached  the  stage 
of  suppuration,  incision  affords  the  only  ]io[)e  of  relief. 

If  there  is  any  reason  to  suspect  the  co-existence  of  rheumatism, 
salicylate  of  soda  should  be  given.  In  chronic  bursitis,  cither  the 
bursa  may  be  aspirated  and  pressure  afterward  applied,  or  the 
knee  may  be  let  alone.  The  discomfort  is  so  slight  that  occa- 
sionally patients  very  much  prefer  to  have  nothing  done;  however, 
in  these  cases  there  is  always  risk  of  suppuration,  and  when  it  takes 
place  in  chronic  bursitis,  if  let  alone  it  evacuates  itself  through  a 
small  opening  and  a  sinus  is  established,  which  discharges  indefi- 
nitely. The  only  way  to  prevent  this  is  immediately  upon  the 
occurrence  of  suppuration  to  lay  the  entire  bursae  open  by  a  crucial 
incision,  and  either  dissect  out  the  tough  fibrous  sac  which  will  be 
found  there,  or  having  laid  it  open,  scrape  it  out  very  thoroughly 
with  a  Volkmann  spoon.  Any  other  measure  is  useless,  when  the 
inflammation  has  reached  the  stage  of  suppuration. 

Cysts  of  the  Knee-Joint. 

The  occurrence  of  cystic  swellings  in  connection  with  the  larger 
joints,  especially  the  knee-joint,  has  been  called  attention  to  by  Mr. 
Baker  ("St.  Bartholomew's  Hospital  Reports,"  Vol.  13,  page  245; 
Vol.  21,  page  177).  These  swellings  are  found,  from  time  to  time, 
in  the  neighborhood  of  the  knee-joint.  At  first  there  is  nothing  to 
suggest  their  connection  with  the  joint  in  any  way,  for  the  cyst 
may  be  at  a  considerable  distance  from  the  joint.  There  may  be 
no  fluctuation  to  be  obtained  between  the  joint  and  the  cyst,  nor 
can  the  fluid  from  the  cyst  be  pressed  into  the  joint ;  in  fact,  there 
may  be  no  evidence  of  effusion  in  the  joint. 

In  this  case  it  is  almost  impossible  to  believe  that  any  connec- 
tion exists  between  the  cyst  and  the  articulation,  but  the  value  of 
Mr.  Baker's  papers  lies  in  the  fact  that  he  has  pointed  out  the 
almost  universal  connection  of  these  cysts  with  the  joint  cavity. 

As  a  rule,  there  has  been  a  certain  amount  of  effusion  into  the 
joint  which  has  escaped  into  the  neighboring  bursae  or  into  a  her- 
nial protrusion  of  the  synovial  membrane,  while  in  other  cases  it 
seems  clear  .that  the  affection  of  the  joint  was  secondary  to  a  bur- 
sitis. The  treatment  should  be  aspiration  at  first,  and  if  that  fails 
to  give  relief,  as  it  probably  will,  free  incision  of  the  sac  may  be 
attempted,  remembering  always  that,  in  so  doing,  one  is  probably 


414 


OR  THOPEDIC  S  URGER  V. 


opening  the   knee-joint   cavity  and   that   every  possible   antiseptic 
precaution  should  be  taken, 

CJiarcofs  disease  of  the  knee-Joint  presents  in  the  beginning  the 
symptoms  of  arthritis  deformans,  in  addition  to  those  of  spinal- 
cord  disease.  ~  The  affection,  however,  soon  assumes  a  more  serious 
type,  suppuration  occurs  in  many  cases  and  the  ends  of  the  bone 
melt  away  and  dislocation  takes  place  with  excessive  deformity  as 
is  shown  in  the  photographs. 


Fig.  365. — Spinal  Arthropathy  of  the  Knee- 
joint.    (Schreiber.) 


Fig.  366. — Enlargement  of  the  Knee-joint  in  a  Case  of 
Spinal  Arthropathy.     (Morrant  Baker.) 


Excision  of  the  knee-joint  has  been  performed  in  four  such  cases; 
Rotter  {Archiv  f.  Chir.,  1887,  36,  page  127)  has  operated  with 
fair  results  in  two  of  the  cases,  but  such  treatment  must  be  very 
exceptionally  indicated  and  can  be  of  but  little  use. 

The  affection  is  steadily  progressive,  in  most  cases  to  a  fatal 
issue. 

Dislocation  of  the  patella  is  likely  to  occur  spontaneously  or  for 
very  slight  cause  in  certain  young  girls  with  lax  muscular  fibre  and 
a  feeble  development,  but   boys  are  only  exceptionally  attacked. 


OTIII'IR    D/S/wiSKS   ()!•     Till'.    k'N ICI'.-jOfA'T.  415 

In  consequence  of  some  sli^fht  twist  of  the  le^s  as  in  dancing,  rising 
from  a  chair,  going  up-stairs  or  some  similar  motion,  an  excruciat- 
ing pain  is  felt  in  the  knee,  and  the  t)erson  either  falls  in  conse- 
quence of  faintness,  or  fmds  herself  unable  to  use  the  leg.  Very 
often  the  patient  herself  hears  a  cracking  sound  vvlien  the  dislocation 
occurs.  The  patella  is  found  almost  always  dislocated  outwardly, 
sometimes  twisted  so  that  its  lateral  edge  rests  against  the  front  of 
the  femur  (vertical  luxation  of  Malgaignej.     The  reduction  of  the 


••-■\ 


Fig.  367. — Spinal  Arthropathy  of  the  Knee-joint.     The  same  as  the  preceding,  showing  the  alterations  in 
the  articular  surfaces.     (Morrant  Baker.) 

dislocation  is  very  simple  and  is  ver}'  soon  learned  by  the  patients 
themselves.  The  leg  is  fully  extended  and  the  patella  gently 
pressed  back  into  place  until  it  assumes  its  proper  place  with  a 
click,  or  often  it  slips  back  of  its  own  accord  when  the  leg  is 
straightened.  An  attack  of  synovitis  follows,  as  in  the  case  of  loose 
bodies,  but  the  joint  soon  acquires  a  tolerance  so  that  each  suc- 
ceeding attack  of  synovitis  becomes  less. 

The  cause  of  the  affection  seems  to  be,  in  most  cases,  the  lack  of 
tonicity  in  the  extensor  muscles  of  the  thigh,  or  the  elongation  of 
the  ligamentum  patellae,  but-very  commonly  the  former. 


4-i6 


ORTHOPEDIC  SURGERY. 


Treatment  should  be  addressed  to  strengthening  the  general  sys- 
tem, to  systematic  exercises,  and  hygiene.  Massage  of  the  anterior 
thigh  muscles  is  likely  to  be  beneficial. 

As  far  as  preventive  treatment  goes,  a  knee-cap  is  required  in 
the  worst  cases,  and  in  the  milder  ones  the  measures  already  indi- 
cated, together  with  the  use  of  a  flannel  bandage,  will  ordinarily  be 
sufficient  to  overcome  the  tendency  to  dislocation  at  any  time.     In 


Fig.  368. — Spinal  Arthropathy  of  the  Knee-joint.     (Morrant  Baker.) 

general  it  is  better  to  attack  the  cause  of  the  affection  and 
strengthen  the  muscles  rather  than  to  depend  upon  mechanical  ap- 
pliances to  prevent  the  displacement.  It  is  surprising  in  these 
cases  to  see  how  slight  a  wrench  or  twist  will  cause  a  complete 
and  very  painful  dislocation. 

Disease  of  the  Meniscus. — A  few  cases  have  been  reported  of 
primary  disease  of  the  semilunar  cartilages ;  the  disease  was,  how- 
ever, only  demonstrated  after  opening  the  joint. 

Kocher' reported  three  cases  of  circumscribed  fungous  disease 
'  Cent.  f.  Chin,  Nov.  5fh,  1881. 


OTHER   DISI'lylShiS    1)1'     T/I/C    K X Eh'.-JOl NT. 


417 


of  the  internal  meniscus.  In  one  of  these,  i^niipuncture  and  re- 
moving the  granulations  by  scraping  resulted  in  recovery;  in  two, 
extirpation  of  the  affected  meniscus  was  followed  by  a  cure,  with 
active  motion  of  the  joint.  In  a  fourth  case,  the  external  semi- 
lunar cartilage  was  removed  on  account  of  chronic  inflammation 
and  a  relaxed  condition,  which  interfered  with  locomrjtifm.  The 
operation  resulted  in  healing  by  first  intention. 

Rupture  of  the  tendon  of  the  patella^  is  recorded  as  having  hap- 


P^f~ 


Fig.  369.     Spontaneous  Luxation  in  Spinal  Arthropathy.     (Schreiber.) 

pened  to  a  patient  thirty-eight  years  of  age,  who  ten  years  before 
had  suffered  from  a  severe  attack  of  acute  rheumatism;  a  lighter 
attack  followed  later,  and  again  another  six  months  before  the 
accident.  The  tendon  was  ruptured  on  the  first  attempt  at  walking 
after  this  attack,  on  making  a  step  upward,  the  separation  taking 
place  directly  under  the  patella.  The  treatment  employed  was 
simply  an  appliance  to  aid  in  locomotion. 

Functional  affections  of  the  knee-joint  Avill  be  considered  in  the 
Chapter  devoted  to  functional  joint  disease. 


'  Mennier,  Gaz.  des  Hop.,  iSSi,  No.  1,121. 


27 


CHAPTER    X. 

DISEASES    OF   THE    JOINTS    OF   THE   ANKLE    AND 

FOOT. 

Diseases  of  the  Ankle-joint. — Simple  Synovitis  and  Ostitis. — Symptoms. — Di- 
agnosis.— Treatment.— Arthritis  Deformans. — Diseases  of  the  Scapho- 
cuneiform  Articulation. — Diseases  of  the  Metatarso-phalangeal  Articula- 
tion.— Bursitis  of  the  Ankle. 

Simple  Synovitis. 

Simple  Synovitis  of  the  ankle-joint  is  not  common,  and  when  it  is 
present  it  is  usually  the  result  of  injury.  Owing  to  the  anatomical 
relations  of  the  parts,  serous  or  purulent  effusion  within  the  joint 
can  take  place  only  to  a  limited  extent.  Peri-articular  swelling  is 
a  marked  and  early  symptom,  owing  to  the  fact  that  the  soft  parts 
next  the  joint  are  not  hidden  under  a  thick  layer  of  muscle  or  fat. 

In  simple  chronic  synovitis  the  foot  may  be  held  extended  be- 
yond a  right  angle  and  at  the  tibio-tarsal  angle  in  front  more  or 
less  prominence  is  found  when  the  capsule  is  distended  with  fluid. 
This  is  limited  above  and  below,  and  sometimes  the  swelling  can 
be  seen  to  have  raised  the  anterior  tendons,  and  it  is  sometimes  pos- 
sible to  detect  fluctuation  here.  There  is  also  likely  to  be  a  slight 
swelling  at  the  sides  of  the  tendo  Achillis.  In  simple  chronic  syn- 
ovitis motion  is  generally  but  little  limited  and  not  very  painful,  or 
but  slightly  so,  so  that  a  weakness  and  stiffness  of  the  joint  with 
occasional  pain  are  the  only  symptoms  complained  of. 

Chronic  Fungous  Synovitis. 

Simple  chronic  synovitis,  however,  is  not  by  any  means  so  com- 
mon in  the  ankle-joint  as  chronic  fungous  synovitis,  which  is  a  much 
more  grave  affection  and  is  at  times  the  outcome  of  simple  chronic 
synovitis.  More  commonly,  however,  it  follows  either  a  trauma- 
tism or  develops  in  strumous  patients  without  an  assignable  cause. 
It  is  very  likely  to  go  on  to  disease  of  the  bone  and  in  many  cases, 
probably  the  majority  in  children,  the  process  begins  in  the  bone 
and  the  synovial  affection  is  secondary,  as  in  tumor  albus  and  hip 
disease.     In  those  cases  where  it  begins  in  the  synovial  membrane^ 


DISEASES  01'  Till-:  j()i.\rs  or-  riiE  ankij-:  and  /■oov.  ^kj 

the  symptoms  so  gr;i(lii;illy  mcr^c  into  those  of  Ijonc  (h'scasc,  that 
it  is  impossible  to  say  where  one  ends  and  the  other  begins.  Prac- 
tically one  may  consider  under  one  head  those  cases  of  chronic 
tuberculous  disease  of  the  ankle  which  begin  in  the  synovial  mem- 
brane and  those  which  begin  in  the  bone,  for  in  either  event  a 
chronic  fungous  synovitis  will  be  present  and  play  the  chief  role  in 
the  causation  of  symptoms." 

Symptoms. — The  seat  of  the  disease,  when  beginning  in  the  bone, 


,//' 


Fig.  370. — Swelling  of  the  Joint  in  Disease  of  tlie  Ankle 


Fig.  371. — Advanced  Chronic 
Joint  Disease  of  the  Ankle 
with  the  Foot  in  a  Position  of 
Talipes  Equinus. 


may  be  in  the  articular  end  of  the  tibia  or  in  the  astragalus;  and 
other  adjacent  bones  may  be  involved  secondarily  or  simultane- 
ously, as  the  OS  calcis,  the  scaphoid,  cuboid,  and  cuneiform  bones. 
Affection  of  these  latter  bones  may  also  exist  alone.  The  affection 
is  not,  as  a  rule,  a  painful  one,  but  in  certain  cases  it  may  assume 
this  type  and  night  cries  may  accompany  an  exquisite  tenderness 
of  the  whole  joint  to  pressure  and  motion.  Tenderness,  as  a  rule, 
is  present  over .  the  joint  capsule  in  front,  and  perhaps  under  the 
malleoli,  and  swelling  and  heat  are  invariable  accompaniments  of 
the  affection.     Muscular  rigidity  is  marked  in  serious  cases. 

^-Viinals  of  Anat.  and  Surg.,  May,  1SS2. 


420 


ORTHOPEDIC  SURGERY. 


Lameness  is  an  early  and  a  marked  symptom.  Sometimes  it  is 
produced  by  the  pain  which  weight-bearing  causes  in  walking,  but 
more  often  by  the  muscular  stiffness  which  will  not  allow  the  ankle- 
joint  to  bend. 

The  swelling  consists  of  a  boggy  infiltration  of  the  soft  parts 
around  the  ankle,  along  with  a  distention  of  the  joint  capsule  by 
gelatinous  granulations.  In  character  it  is  oedematous,  and  fluctu- 
ation means  the  presence  of  abscess. 

This  swelling  is  uniform  around  the 
ankle,  except  where  an  abscess  is  point- 
ing on  one  side.  The  depressions  in 
the  contour  of  the  ankle  in  front  and 
behind  the  malleoli  disappear  in  the 
swelling,  and  the  foot  is  extended  and 
slightly  abducted.     The  foot  in  affec- 


^-w^'*^" 


Fig.  372. — Ankle-joint  Disease  of  the  toot  at  an 
Eai'ly  Stage. 


Fig.  373. — Ankle-joint  Disease.     (Schreiber.) 


tions  of  the  ankle-joint  usually  assumes  a  position  with  the  toes 
pointing  downward,  and  in  chronic  cases  with  the  foot  slightly 
rolled  outward  (in  the  position  of  equino  valgus).  This,  however, 
is  not  the  only  malposition,  for  the  foot  may  assume  the  position 
of  pure  talipes  calcaneus,  but  the  position  of  pure  talipes  equinus 
is  more  common  than  this.  These  malpositions  are  not  in  conse- 
quence of  the  distention  of  the  joint,  but  are  brought  about  by  the 
abnormal  tonic  muscular  contraction,  and  these  deformities  yield 
of  themselves  and  the  foot  returns  to  its  normal  position  when  the 
irritation  is  quieted  in  the  joint  by  proper  treatment. 

Wasting  of  the  thigh  and  calf  muscles  occurs.     Abscess  is  likely 
to  occur,  and  may  point  in  any  part  of  the  joint. 


DiSEASi<:s  c;/'"  Tifi'.  j()i.\'Ts  ()/■'  Tiir:  /iNk'i.h:  amp  i^oot.  421 

When  the  disease  attacks  the  incdio-tarsal  or  tarso-inetatarsal 
joints,  the  anterior  part  of  tlie  instej)  appears  swollen  and  is  hot 
and  tender.  Motion  at  the  ankle  is  but  little  restricted,  but  motion 
of  the  anterior  part  of  the  foot  u[)on  itself  is  attended  by  pain  and 
is  probably  lost.  Tlie  location  of  the  affection  is  evident  from  a 
slight  examination.  In  the  same  way  it  sometimes  attacks  the  os 
calcis  and  is  manifested  by  the  same  symptoms  of  local  inflamma- 
tion without  any  symptoms  referable  to  the  ankle-joint. 

Diagnosis. — The  recognition  of  disease  of  the  ankle  is  dependent 
on  the  usual  symptoms  of  limping,  limitation  of  motion  of  the 
joint,  stiffness,  swelling  of  the  joint,  pain,  and  tenderness.  The 
prominence  of  these  symptoms  varies  with  the  activity  and  extent 
of  the  disease. 

A  diagnosis  between  synovitis  without  effusicjii  and  ostitis  is  not 
necessary  for  treatment. 

Teno- Synovitis  gives  rise  to  swelling  around  the  tendons;  there 
may  be  some  pufifiness  of  the  skin,  heat,  hyper^esthesia  and  pain  on 
movement  of  the  foot;  but  extreme  change  in  contour  of  the  ankle 
is  not  present,  and  the  pain  is  chiefly  that  of  apprehension.  In 
manipulating  the  foot,  a  creaking  at  the  painful  spot  is  felt,  and 
this  spot  itself  is  sharply  localized,  and  as  a  rule,  is  not  over  the 
joint,  but  in  the  course  of  the  tendons. 

The  most  troublesome  affections  to  diagnosticate  from  ankle- 
joint  disease,  are  the  functional  affections  which  result  often  from 
sprains  and  injuries.  Here  it  is  not  uncommon  to  find,  in  hyper- 
sensitive women  chiefly,  a  limitation  of  motion  of  the  ankle,  with 
much  pain  on  manipulation  and  pressure;  there  may  be  slight 
swelling  left  over  from  the  injury,  and  the  question  to  be  decided 
is,  whether  any  disease  of  the  joint  exists  which  can  well  be  made 
worse  if  the  patient  goes  about,  or  if  it  is  purely  a  subjective  affair 
which  can  be  overcome  by  judicious  management.  In  one  case  rest 
is  indicated,  in  the  other,  activity.  The  diagnosis  of  functional  joint 
disease  is  considered  in  full  in  the  proper  place  in  Chapter  XXV. 

In  many  cases  the  treatment  is  too  soon  discontinued  after 
sprains,  and  a  teno-synovitis  or  subacute  inflammation  of  part  of 
the  synovial  sac  may  persist,  and  be  accompanied  by  local  heat 
and  tenderness.  It  matters  not  so  much  how  long  after  a  sprain  is 
found  in  the  ankle-joint,  local  heat  is  a  most  important  sign ;  it 
indicates  the  need  of  rest  and  shows  that  the  affection  of  the  joint 
is  at  least  not  altogether  hysterical. 

Again,  it  should  be  repeated,  that  one  must  depend  chiefly  upon 
the  existence  of  the  objective  signs  of  ankle  disease,  rather  than 
upon  the  patient's  feelings;  allowing,  however,  due  weight  to  the 
history  of  the  affection  and  the  patient's  sex  and  constitution. 


422 


ORTHOPEDIC  SURGERY. 


Treatment. — The  general  principles  of  the  treatment  of  chronic 
joint  disease  are  nowhere  more  applicable  than  in  ankle-joint  dis- 
ease, although  they  are,  of  course,  modified  by  the  anatomical  con- 
ditions present.  Traction  is  not  applicable  as  a  mode  of  treatment, 
from  the  difficulty  of  applying  it,  so  that  one  turns  to  fixation  and 
protection. 

Protection  from  jar  is  especially  indicated — as  will  be  readily 
seen,  if  it  be  borne  in  mind  that  in  locomotion  the  whole  weight  of 
the  body  is  borne  at  each  step  upon  the  comparatively  small  sur- 
face of  the  articulating  portion  of  the  astragalus.  Fixation  of  the 
ankle  in  a  stiff  bandage  and  allowing  the  patient  to  walk  upon  the 
limb,  is  a  manifest  error,  as  affording  little  or  no  real  protection  to 
the  joint.  Fixation  is  of  advantage  in  the  more  acute  stages  of 
the  affection,  and  is  readily  furnished  by  means  of  stiff  bandages. 
A  plaster-of-Paris,  bandage  is  the  most  convenient  appliance, 
and  should  be  carried  above  the  knee  so  as  to  fix  that  joint  also. 
Silicate  and  dextrin  bandages  are  more  durable,  but  more  com- 
plicated in  their  application.  Protection  can  be  furnished  either 
by  means  of  crutches,  or,  more  thoroughly,  by  means  of  protective 
splints  with  perineal  supports.  Protective  splints,  described  for 
the  knee-joint,  are  needed  in  ostitis  of  the  ankle.  The  Thomas 
knee-splint  is  generally  the  most  available.  The  form  of  ankle 
splint  advocated  and  used  by  Dr.  Shaffer  is  particularly  useful, 
but  it  possesses  the  disadvantage  of  being  complicated  and  rather 
expensive. 

Unless  the  disease  is  far  advanced,  children  who  are  in  good  con- 
dition, as  a  rule,  do  well  under  conservative  treatment.  Adults  do 
not  make  such  good  progress;  but  conservatism  should  first  be 
tried.  If  abscesses  form,  they  should  be  inci-sed  and  traced  to 
their  source,  and  if  loose  bone  is  detected  this  should  be  removed. 
If  the  foot  assumes  a  malposition,  this  should  be  corrected ;  and 
this  is  best  done  by  applying  a  plaster  bandage  to  the  foot  in  its 
malposition  and  quieting  thereby  the  inflammation  so  much  that  in 
two  weeks  the  malposition  will  be  found  less  and  an  improved 
position  can  be  gained.  The  general  health  should  be  carefully 
inquired  into  and  appropriately  treated.  All  these  procedures  may 
be  grouped  together  and  be  said  to  complete  the  expectant  method 
of  treatment.  The  results  of  this  branch  of  the  conservative  sur- 
gery of  the  ankle-joint  in  chronic  disease,  have  been  very  carefully 
studied  by  Dr.  Gibney,  of  New  York.' 

The  results  of  Dr.  Gibney's  instructive  investigations  are  in  brief, 
as  follows : 

Observations  were  made  upon  30  cases. 
'  N.  Y.  Med.  Rec,  Aug.  21st,  1880,  p.  197;  Am.  Jour.  Obstet.,  1880,  p.  434. 


DISEASES  OF  Til  hi  JOI  NTS  Ol'    1 1 1  hi  ANKLI-l  AND  l-iM)'/'.    423 

The  minimuin  duraticjii  (>f  the  (hsease  was  i  year. 

The  maximum  duration  of  tiie  disease  was  6  years. 

The  average  duration  ot  the  disease  was  3  years  and  3  months. 

The  average  time  of  treatment  was  i  year  and  3  months. 

In  19  cases  suppuration  was  very  extensive. 

In  6  cases  suppuration  was  moderate. 

In  5  cases  suppuration  was  absent. 

The  disease  occurred  in  young  children,  the  h'mbs  were  sh'ghtly 
shortened,  and  the  calf  was  atrophied.  20  patients  did  not  limp  at 
all,  and  7  only  slightly.  There  were  one  or  two  cases  in  which 
some  deformity  appeared  in  the  foot  after  use. 

The  conclusion  drawn  from  a  study  of  these  facts,  together  with 
a  careful  study  of  each  of  the  cases  by  itself,  is  that  the  expectant 
plan  fully  carried  out  is  justifiable  in  a  large  proportion  of  cases, 
and  that  the  results  obtained  are  good.  In  cases  of  caries  of  the 
ankle,  with  extensive  disease  of  bone,  the  decision  of  continuance 
of  conservative  treatment,  or  the  adoption  of  operative  interference, 
is  one  which  is  based  largely  upon  the  patient's  age,  and  the 
circumstances  of  attendant  care. 

There  are  three  alternatives  left  if  the  expectant  method  fails  to 
give  a  satisfactory  result  after  due  trial  has  been  made  of  it. 
The  mildest  form  of  operative  interference  consists  in  curetting 
the  sinuses,  but  the  removal  of  the  whole  diseased  tarsal  bone  may 
be  necessary.  It  will  be  found  that  the  latter  procedure  gives 
much  more  satisfactory  results  where  the  ostitis  has  become  so  ex- 
tensive as  to  have  occasioned  sinuses,  and  the  curette  is  unrelia- 
ble as  a  means  of  removing  all  the  affected  tissue.  Occasionally  it 
may  be  possible  to  scrape  out  a  focus  of  tuberculous  material  in 
the  OS  calcis,  but  in  the  tarsus  proper  it  is  rarely  a  satisfactory 
procedure.  The  second  operation  is  a  formal  excision  of  the  dis- 
eased bones.  The  third,  and  most  radical  measure,  is  amputation 
of  the  leg  or  foot. 

In  1670  Fabricius  Hildanus  excised  the  entire  astragalus  for  a 
complicated  luxation.  G.  F.  Moreau  first  performed  a  total  ex- 
cision in  April,  1792.  The  first  excision  for  disease  in  the  United 
States  was  done  by  Thomas  Welles,  of  Columbia,  South  Carolina, 
in  wdiich  the  entire  astragalus  was  removed.  Hodges,  Culbertson, 
and  Connor  have  investigated  with  great  care  all  cases  of  excision 
of  the  ankle  and  tarsus,  including  cases  up  to  18S3. 

Hodges  felt  that  the  very  precipitate  manner  of  reporting  cases 
failed  to  show  the  best  results,  which  the  cases,  if  reported  more 
deliberately,  might  afford.  Then,  too,  there  were  many  varieties 
of  opinion  as  to  what  constitutes  a  useful  limb.  He  was  also  im- 
pressed with  the  great  length  of  time  necessary  to  insure  a  cure ; 


424  ORTHOPEDIC  SURGERY. 

which  he  found  to  be  much  greater  in  excision  of  the  ankle  than 
after  any  other  excision.  In  i8  successful  reported  cases,  an  aver- 
age of  287^  days,  or  over  9  months,  were  necessary  for  a  cure. 

Culbertson  brought  all  excision  records  up  to  1873.  He  tabu- 
lates 124  cases  excised  for  disease.  Of  these,  perfect  results  were 
obtained  in  5.55  per  cent.  A  useful  foot  in  60.18  per  cent,  and  2.77 
per  cent  were  not  useful,  and  it  was  necessary  to  amputate  the  foot 
in  12.03  P^i"  cent  of  the  cases.  The  mortality  table  states,  that  of 
the  124  cases,  about  8.5  per  cent  died  from  the  operation. 

Dr.  A.  T.  Cabot '  recently  reported  the  results  in  a  series  of  eight 
excisions  of  the  ankle  in  children,  done  at  the  Boston  Children's 
Hospital.  These  cases  were  not  selected,  but  were  taken  as  they 
were  found.  They  may  be  spoken  of  here  as  showing  what  the 
end  results  are  likely  to  be  in  cases  of  carefully  performed  excision. 
The  cases  in  question  had  been  operated  on  from  one  to  seven 
years  previously  and  all  the  joints  were  solidly  healed  and  free 
from  tenderness  and  swelling.  In  one  there  was  a  slight  tendency 
to  pes  varus,  and  in  one  a  slight  equinus;  but  in  both  cases  it  was 
so  slight  that  it  did  not  interfere  with  walking.  Dr.  Cabot  advo- 
cates most  strongly  the  removal  of  the  whole  of  every  small  bone 
which  shows  signs  of  disease. 

Both  Hodges  and  Culbertson's  cases  were  reported  before  the 
days  of  antiseptic  surgery.  The  long  time  then  necessary  for  heal- 
ing of  the  operation  wound  is,  under  present  methods  of  wound 
treatment  much  shortened,  and  suppuration  is  infrequent.  Cases 
are  being  reported  to-day  with  greater  accuracy  and  in  fuller  detail. 
Hence  the  great  value  to  be  attached  to  the  reports  of  Connor's 
108  cases.  He  found  that  in  10.53  P^''  cent  there  were  failures  ; 
6.32  per  cent  could  walk  with  a  cane;  24.21  per  cent  could  walk 
and  not  limp;  and  47.37  per  cent  had  good  results.  The  foot  is 
shortened  and  broadened.  The  ankle  motions  vary.  The  short 
ening  of  the  limb  varies,  but  is  slight.  In  a  few  cases  an  osseous 
regeneration  occurs.  Connor  finds  that  an  excision  of  the  whole 
or  part  of  the  tarsus  is  not  much  more  dangerous  than  an  ankle- 
joint  amputation,  and  subsequent  removal,  of  the  foot  is  possible  if 
desired. 

The  prognosis  has  been  partially  alluded  to.  The  question 
arises :  Will  the  disease  in  the  foot  cease  if  the  bone  is  removed  ? 
It  may  emphatically  be  said  that,  if  thoroughly  removed  in  chil- 
dren, relapse  is  unlikely  to  occur.  More  relapses  occur  from 
partial  operations  and  from  gougings  and  scrapings  than  from 
any  other  cause.  The  disease  reappeared  in  three  of  Connor's 
cases,  but  in  none  of  Cabot's  was  there  relapse.  The  earlier  the 
'  Boston  Med.  and  Surg.  Journ.,  March  22d,  1888. 


DISEASES  OF  THI'.  JOINTS  ()/<'   77/ IC  /INK/.E  AND  FOOT.    425 


excision  is  done,  and  the  more  hone  removed  frf;in  the  tarsus,  the 
better  is  the  result.  Connor  has  twice  removed  the  entire  tarsus 
(in  adults)  and  good  results  have  followed  in  each  case. 

In  excision  of  the  ankle  the  preference  has  always  been  for  lat- 
eral incisions  in  the  length  of  the  leg,  as  they  cut  no  tendrnis  trans- 
versely and  give  fairly  good 

access  to  the  interior  of  the  ;         ,.    » 

joint;  but  the    exposure    of 
the    articular  surface   is   im- 
perfect   by    these    methods 
and  the  disease  may  be  thus 
overlooked.     The  figure.' 
show  a  very  good  modifica- 
tion of  the    lateral    incision 
devised  by  Wyeth.    The  ope- 
ration should  be  performed  | 
by  the  sub-periosteal   meth-  ^^ 
od;    the    diseased  tissue   re-    I 
moved  from  the  ends  of  the     | 
leg  bones  and  the  astragalus    |' 
removed  entire  with  the  top   s ;' 
of  the  OS  calcis,  if  diseased.   \: 
Wyeth    then    nails    the    os     ^' 
calcis  to  the  leg  bones.    The 

1  -1  r        1  •  •     Figs.  374  and  375. 

detail    of    the    operation    is 

entirely  like  that  of  the  other  operations  mentioned  above. 

There  are  all  sorts  of  modifications  of  these  lateral  incisions  and 
other  incisions  radically  differing;  but  of  all  methods  preference 
must  be  given,  in  the  opinion  of  the  writers,  to  that  of  Kocher, 


Fig.  375. 
-Wyeth's  Method  for  Ankle-joint  E.xcision. 


Fig.  376.— Posterior  Wire  Splint  for  Ankle-joint  Excision. 

which  has  proved  eminently  satisfactory,  more  so  than  the  lateral, 
or  any  other  incision. 

The  method  is  as  follows:  The  foot  is  held  at  a  right  angle  and 
a  superficial  incision  is  made  along  the  outer  border  just  below  the 
external  malleolus,  reaching  from  the  tendo  Achillis  to  the  exten- 
sor tendons.  The  peroneal  tendons  are  dissected  out,  secured  by 
sutures,  and  then  cut  by  a  second  and  deeper  incision.     The  ankle- 


426 


ORTHOPEDIC  SURGERY. 


joint  is  opened  very  easily  and  the  capsule  along  the  anterior  and 
posterior  surfaces  of  the  tibia  is  cut.  The  foot  is  then  dislocated 
inward  as  far  as  is  desired,  and  the  joint  can  be  inspected  to  any 

extent.  After  the  diseased 
parts  have  been  removed, 
the  foot  is  reduced  to  its 
proper  position,  the  pero- 
neal tendons  united,  and 
the  wound  closed.  The 
operation  differs  from  that 
of  Reverdin  in  not  cutting 
the  tendo  Achillis  and  in 
preserving  the  peroneal 
tendons. 

When  the  foot  is  dislo- 
cated, a  very  admirable 
view  is  obtained  of  the  in- 
terior of  the  joint;  all  the 
bones,  being  very  accessi- 
ble, can  be  inspected  care- 
fully, and  removed  with- 
out difficulty. 

The  osteoplastic  resec- 
tion of  Mikulicz  '  is  a  sub- 
stitute for  amputation  in 
cases  of  very  serious  dis- 
ease of  the  posterior  bones 
of  the  foot.  The  opera- 
tion had  previously,  how- 
ever, been  devised  by 
Wladmiroff.- 

The  operation  is  a  seri- 
ous one,  but  in  16  out  of 
22  cases  reported  the  re- 
sults have  been  good ;  2 
died,  and  3  required  sub- 
sequent amputation. 

The  after-treatment  of 
ankle-joint  resection  is 
similar  to  the  treatment 
of  the  other  resections  spoken  of.  Asepsis,  and  immobilization 
in  a  correct  position  are  the  requirements;  and  for  this  end  in- 
frequent   dressings  are  very   desirable.       Plaster  of  Paris   applied 


Figs.  367,  ; 


Fig.  378. 

-Forms  of  Wire  Splints  for  Treatment  of 
the  Ankle  after  Excision. 


'  Archiv  f .  Klin.  Clin. ,  xxvi. 


Med.  News,  Dec.  3d,  i^ 


DJSKAsi-:s  oi''  rill':  JOINTS  o/'-  tiii:  anki.!:  and  /■oot.  427 

outside  of  a  heavy  dressin^^  is  very  servieeable,  as  in  knee-joint 
excision.  An  accurate  and  ecjually  efficient  splint  is  a  wire 
posterior  splint,  which  is  made  of  a  rod  of  "  copper-washed  iron 
wire  "  three-sixteenths  of  an  inch  in  diameter,  which  is  bent  to  fit 
the  leg  and  padded  except  at  the  ankle,  where  it  is  covered  with 
rubber  tubing  and  can  be  rendered  aseptic  and  incorporated  in  the 
dressing  there.  The  rest  of  the  splint  is  padded  (Fig.  376;.  One 
can  also  use  an  anterior  wire  splint. 

But  whatever  splint  is  used,  the  point  about  which  one  must  be 
most  careful  is  to  see  that  the  foot  is  at  a  right  angle  to  the  leg 
and  in  the  same  plane.  For  a  long  time  after  excision  the  joint 
should  be  protected  from  weight-bearing  by  the  application  of  a 
Thomas  splint,  or  some  such  appliance. 

Siuniiiai'y. — In  short,  the  treatment  of  the    diseased   ankle-joint 


Fig.  379.  — Shoe  for  Metatarsal  Disease. 

should  be  at  first  conservative.  If  these  measures  fail  after  faithful 
trial,  thorough  removal  of  the  diseased  tarsal  bones  should  be  at- 
tempted and  amputation  regarded  strictly  as  a  last  resort. 

Chronic  artJiritis  deformans  of  the  ankle-joint  does  not  often 
occur  alone,  but  in  connection  with  the  manifestations  of  the  affec- 
tion in  other  joints.  The  symptoms  differ  in  no  way  from  the 
symptoms  of  the  affection  described  in  the  other  joints. 

ScapJw-Cuneiforni  Articulation. —  Erichsen  and  Gosselin  have  de- 
scribed a  rare  affection  of  this  complicated  articulation.  Motion 
at  the  ankle  is  free,  but  \veight  cannot  be  borne  in  severe  cases  by 
the  foot.     At  a  later  stage  the  front  of  the  foot  becomes  swollen.' 

Metatarso-PJialangcal  Articulations. — These  joints  are  occasionally 
attacked  as  a  result  of  injury.  In  chronic  rheumatoid  arthritis 
they  may  also  be  attacked.  Inflammation  of  the  metatarso-phalan- 
geal  articulation  of  the  great  toe  takes  place   consequent   on   the 

'  Gazette des  Hopitaux,  October  6th,  1877;  Chambard:  These  de  Paris,iS87:  "  Tarsal- 
gie  des  Adolescents,"  Gazette  des  Hopitaux,  October  gth,  1S79:  Erichsen  ;  "  Science  and 
Art  of  Surgery,"  3d  ed.,  p.  715. 


428  ORTHOPEDIC  SURGERY. 

distortion  of  the  toe  called  "  hallux  valgus,  or  in-toe,"  the  result  of 
fmperfect  shoes,  and  also  secondarily  to  the  affection  well  known 
as  bunion.  A  chronic  rheumatoid  arthritis  of  the  joint  is  common, 
and  it  is  a  favorite  seat  for  gout.  An  ankylosis  of  this  joint  occurs 
in  adolescents,  probably  a  sequel  to  a  long-continued  subacute  in- 
flammation, the  result  also  of  imperfect  shoes.  Nothing  especial 
need  be  said  of  inflammation  of  the  phalangeal  articulations,  ex- 
cept that  they  are  not  common.  Excision  of  the  smaller  joints  of 
the  foot  is  rarely  required.  When  it  is  necessary,  however,  it  is 
done  by  any  simple  method  which  seems  applicable.  Other  affec- 
tions of  the  joints  of  the  feet  are  considered  under  "  acquired 
affections  of  the  feet." 

Bursitis. — A  form  of  bursitis  occasionally  occurs  near  the  ankle 
which  needs  only  to  be  mentioned.  It  is  an  inflammation  of  the 
deep  bursa  which  lies  between  the  os  calcis  and  the  tendo  Achillis. 
It  is  manifested  by  a  dull  aching  pain  in  the  heel,  which  is  made 
worse  by  exercise  and  is  aggravated  by  wearing  boots,  especially  if 
too  short. 

It  affects  most  commonly  children,  but  sometimes  adults  acquire 
it  by  the  wearing  of  injudicious  shoes.  It  generally  subsides  read- 
ily under  proper  treatment,  which  consists  of  rest  and  counter-irri- 
tation. 


CHAPTER    XI. 

DISEASES    OF   THE    SHOULDER,    ELBOW,   AND 
WRIST   JOINTS. 

Shoulder-Joint. —  Acute  Synovitis. — Chronic  Serous  Synovitis.  —  Ostitis. — 
Chronic  Rheumatoid  Arthritis. — Periarthritis. — Charcot's  Disease. — Syn- 
ovial Cysts  and  Bursae. — Treatment  of  Shoulder-Joint  Diseases. — Elbow- 
Joint. — Synovitis.— Ostitis. — Chronic  Rheumatoid  Arthritis. — Urethral 
Arthritis. —  Charcot's  Disease. —  Syphilitic  Disease. —  Peri-articular  Dis- 
ease and  Stiffness  of  the  Elbow. — Treatment  of  Elbow-Joint  Diseases. — 
Diseases  oj  the  Wrist  Joint.  —  Ostitis.  —  Teno-Synovitis.  —  Rheumatoid 
Arthritis. — Treatment  of  Wrist-Joint  Disease. 

Diseases  of  the  Shoulder-Joint. 

Aaite  synovitis  of  the  shoulder  is  not  a  common  affection,  and 
rarely  occurs  as  the  result  of  injuries,  exposure  to  cold  and  the 
like.  When  it  is  met,  it  is  more  likely  to  have  been  caused  by 
pyaimia,  rheumatism,  or  the  exanthemata,  and  as  is  usually  the  case 
with  these  affections,  it  tends  toward  a  rapid  suppurative  course. 
The  physical  signs  of  the  affection  do  not  differ  (except  in  their 
more  acute  character)  from  those  described  in  the  next  section 
under  chronic  serous  synovitis.  The  treatment  during  the  acute 
stage  is  rest  and  soothing  applications  with  compression.  When 
pus  has  formed,  the  only  treatment  to  be  considered  is,  of  course, 
free  incision.  The  acute  arthritis  of  infants  is  occasionally  ob- 
served in  this  joint,  where  it  presents  its  usual  characteristics. 

Chronic  serons  synovitis  of  the  shoulder  is  a  rare  affection,  most 
frequently  met  with  in  young  children,  either  as  a  sequel  of  an 
acute  attack,  the  result  of  some  injury,  or  as  a  slow,  persistent  pro- 
cess, beginning  with  slight  symptoms  easily  disregarded. 

Pain  is  either  absent,  or  so  slight  as  to  often  escape  attention. 
The  earliest  symptom  to  attract  notice  is  stiffness,  observed  partic- 
ularly in  forced  movements,  as  in  placing  the  hand  on  the  head, 
etc. 

A  sliglit  fulness  about  the  joint  may  be  detected  at  this  time,  the 
humero-pectoral  groove  being  indistinct,  and  the  depression  below 
the  acromion  obliterated.  Although  an  increase  of  surface  tem- 
perature may  often  be  detected,  its  absence  is  of  little  importance, 
the  joint  being  so  thoroughly  covered.     As  the  disease  progresses, 


430 


ORTHOPEDIC  SURGERY. 


the  case  presents  an  exaggeration  of  the  early  symptoms;  motion 
becomes  more  restricted,  swelling  increases  as  effusion  takes  place, 
the  shoulder  appearing  broader,  and  elevations  replacing  the  natu- 
ral depressions.  Atrophy  of  the  deltoid  and  scapular  muscles 
gradually  occurs,  but  to  a  less  extent  than  in  the  forms  of  ostitis. 

Pain  is  a  symptom  of  varying  severity.  In  children  and  persons 
of  feeble  constitution,  the  affection  may  pass  on  to  a  secondary 
inflammation  and  destruction  of  the  cartilage  and  bone.  In  gen- 
eral, the  tendency  is  toward  resolution  with  more  or  less  impair- 
ment of  joint  motion. 

Ostitis. — The  general  symptoms  of  ostitis  of  the  shoulder  differ  in 
no  way  from  those  in  the  usual  form  of  this  disease,  in  other  more 
commonly  affected  joints,  except  that  stiffness  at  the  joint  is  less 
noticeable  on  account  of  mobility  of  the  scapula.  The  disease  is 
insidious,  extremely  chronic,  prone  to  suppuration,  and  decided 
impairment  of  the  joint  is  certain  to  result. 

One  of  the  earliest  signs  of  this  disease  is  pain  of  a  dull  aching 
character,  which  is  usually  aggravated  at  night,  and  is  referred 
either  to  the  joint  itself,  or  to  the  middle  of  the  arm  near  the  in- 
sertion of  the  deltoid.  In  many  cases  this  symptom  is  absent,  or 
very  slight,  and  probably  in  these  the  origin  of  the  disease  is  in 
the  synovial  membrane.  A  slight  increase  of  surface  temperature 
may  be  detected,  but  the  thickness  of  the  coverings  of  the  shoulder- 
joint  renders  this  uncertain.  There  will  usually  be  found  a  tender- 
ness, frequently  localized  over  a  small  area.  The  patient  instinct- 
ively holds  the  arm  at  rest,  and  attempts  at  passive  motion  provoke 
muscular  spasm,  and  if  the  attempt  is  persisted  in  the  humerus 
and  scapula  are  seen  to  move  together.  The  tender  spots  are  gen- 
erally directly  over  the  joint  capsule  in  front  of,  and  behind  the 
head  of  the  bone.  The  stiffness  of  the  arm  is  the  most  characteristic 
feature  of  the  affection. 

Early  in  the  disease,  a  change  in  contour  of  the  joint  becomes 
apparent,  which  is  due  to  enlargement  of  the  head  of  the  humerus 
as  well  as  to  muscular  atrophy. 

When  the  swelling  is  due  to  effusion  within  the  joint,  the  shoulder 
appears  fuller  and  broader  than  normal,  and  this  is  seen  best  in 
looking  down  on  the  patient;  the  natural  depressions  in  front  of 
and  behind  the  joint  become  either  obliterated  or  are  the  sites  of 
prominences. 

If  suppuration  occurs,  the  patient  complains  more  of  pain,  and 
the  swelling  increases.  The  prominence  of  the  swelling  will  depend 
on  the  direction  taken  by  the  pus,  but  will  most  often  be  found 
collected  in  the  axilla,  under  the  deltoid,  or  along  its  anterior  edge. 
The  subsequent  course  is  slow,  the  result  depending  on  the  extent 


SIIOULDI'.R,    ELIIOW,  AND    WRIST  JOINTS.  431 

of  the  carious  process,  which  may  terminate  soon  after  evacuation 
of  the  pus,  or  continue  to  complete  destruction  of  tlic  head  of  the 
humeius. 

The  possible  results  are:  recovery  with  a  simple  stiff  joint  (anky- 
losis), deformity,  and  impaired  muscular  power,  entire  destruction 
of  the  head  of  the  bone;  and  later,  arrest  of  development  of  the 
humerus. 

Chronic  Rheumatic  Arthritis  of  Shoulder. — Next  to  the  knee,  the 
shoulder  is  the  most  frequent  seat  of  this  disease,  when  it  occurs 
in  the  monarticular  form. 

When  one  shoulder  alone  is  affected,  the  history  of  injury  is 
usual,  but  in  the  poly-articular  forms  this  is  not  to  be  expected. 

The  disease  may  first  manifest  itself  to  the  patient  as  a  slight 
attack  of  joint  pain,  tenderness,  and  stiffness,  and  from  this  condi- 
tion pass  into  the  slow  chronic  course,  with  occasional  exacerba- 
tions, or  it  may  begin  insidiously.  The  amount  of  pain  varies,  it  is 
more  or  less  persistent,  but  not  constant,  and  is  dull  and  heavy  and 
usually  worse  at  night.  Stiffness  appears  at  this  time  with  the 
pain,  at  first  only  slight,  and  noticed  in  forced  movements,  when 
the  arm  is  raised  a-bove  the  level  of  the  shoulder.  Both  pain  and 
stiffness  are  more  noticeable  after  a  period  of  rest. 

From  the  appearance  of  these  symptoms  the  disease  is  slow,  ex- 
tending over  months  or  more  before  marked  change  occurs.  As 
the  disease  progresses  the  muscles  waste,  and  in  severe  cases  to  a 
very  noticeable  degree.  A  creaking  sensation,  both  on  active  and 
passive  motion,  is  almost  always  found,  by  placing  the  hand  over 
the  joint.  Later  in  the  disease,  when  the  characteristic  osseous 
changes  occur,  the  arm  can  be  raised  but  a  short  distance  from  the 
side,  and  the  loss  of  muscular  power  is  very  great.  Swelling  inde- 
pendent of  bone  enlargement  sometimes  occurs,  and  is  due  to  effu- 
sion within  the  cavity  of  the  synovial  membrane,  but  is  not  a  com- 
mon occurrence,  and  usually  appears  late  in  the  disease.  Wlien 
;  the  changes  in  the  joint  have  taken  place,  a  characteristic  appear- 
ance of  the  joint  is  found.  The  head  of  the  humerus  is  more 
prominent  in  front  of  the  joint,  while  behind  is  a  depression  as  if 
the  head  of  the  bone  was  displaced  forward,  while  the  shoulder 
droops;  this  being  due  both  to  ligamentous  changes  and  loss  of 
muscular  force. 

Among  the  results  which  may  occur  from  the  change  in  the 
bone,  are  separation  of  the  acromion,  and  displacement  of  the  long 
head  of  the  biceps  from  its  groove,  and  its  subsequent  rupture. 

Periarthritis  of  the  Shoulder. — Duplay  has  described  as  periar- 
thritis of  the  shoulder-joint  a  condition  of  stiffness  not  infrequently 
seen  after  comparatively  slight  ijijuries.     Pain  accompanies  motion 


432 


ORTHOPEDIC  SURGERY. 


beyond  a  certain  limit.  Atrophy  of  the  muscles  is  present,  and  at 
times  there  is  some  spontaneous  pain.  The  arm  becomes  of  com- 
paratively little  use. 

The  diagnosis  of  periarthritis  is  not  based  on  pathological  evi- 
dence, and,  judging  from  clinical  analogy,  it  seems  fair  to  infer  that 
the  affection  may  include  the  synovial  membrane,  constituting  a 
chronic  synovitis  as  well  as  a  periarthritis. 

The  shoulder  is  not  infrequently  the  seat  of  urethral  arthritis, 
but  this  differs  in  no  way  in  its  course  and  symptoms  from  the 
same  disease  in  the  more  commonly  affected  joints. 

Charcot's  disease  occurring  in  the  shoulder-joint  is  less  common 
than  at  the  hip,  knee,  or  elbow,  but  it  presents  no  especial  char- 
acteristics in  thi3  situation,  except  that  the  head  of  the  humerus  and 
the  glenoid  cavity  may  be  worn  away;  the  latter  in  such  a  manner 
as  to  form  a  large  hollow  cavity. 

Roser  reports  a  case  of  absorption  of  the  head  of  the  humerus, 
and  the  formation  of  a  loose  joint  somewhat  similar  to  that  seen 
following  tabes  dorsalis,  where  no  disease  of  the  cord  existed. 

Sytiovial  cysts  may  rarely  be  noted  in  connection  with  the  shoul- 
der; and  enlargement,  of  the  bursa  beneath  the  deltoid  must  be 
mentioned  as  an  affection  which  may  occasionally  be  seen. 

Treatment  of  SJwiilder -Joint  Disease. 

Chronic  Synovitis. — In  synovitis  of  the  shoulder-joint  with  any 
active  inflammation,  the  indication  is  simply  for  rest  and  fixation. 
These  are  readily  secured  by  means  of  a  sling  and  a  bandage 
securing  the  arm  to  the  side.  Compression  will  be  needed  if  there 
is  swelling  and  effusion. 

Fixation  should  not  be  continued  longer  than  there  is  subacute 
inflammation,  and  can  be  gradually  discontinued ;  first  discarding 
the  bandage  and  retaining  the  sling,  which  can  be  discontinued 
later. 

So  long  as  muscular  irritability  exists,  rest  is  indicated.  In  these 
cases  an  increased  arc  of  motion  and  diminished  sensitiveness  will 
usually  follow  a  few  days'  rest  of  the  joint  and  permanent  ankylo- 
sis is  rendered  less  likely  by  the  application  of  timely  immobiliza- 
tion. 

Ostitis. — In  tubercular  ostitis  at  the  shoulder-joint,  the  indications 
for  treatment  are  practically  the  same  as  those  presented  in  chronic 
synovitis. 

Distraction  is  not  indicated  in  disease  of  the  shoulder,  as,  owing 
to  the  laxity  of  the  joint,  the  weight  of  the  dependent  arm,  if  kept 
at  rest,  is  sufficient  to  separate  the  humerus  from  the  opposing 


SHOULDER,    h.IJSDW,  AXl)    WRIST  JOINTS.  433 

bone  surface  of  the  scapular  articulation.  In  painful  cases,  how- 
ever, it  might  be  necessary  t(i  apply  traction  for  a  time,  by  any 
instrument  similar  to  the  short  Sayre  si)lint  figured  for  hip  disease, 
or  even  by  the  weight  and  pulley  traction  applied  during  recum- 
bency. 

The  question  of  the  use  of  forcible  passive  motion  in  the  conva- 
lescent stage  is  a  vexed  one.  Where  the  adhesions  are  chiefly 
peri-articular,  or  localized  in  portions  of  the  joints,  and  are  firm, 
forcible  motion  under  an  anaesthetic  will  be  necessary;  but  in 
the  majority  of  light  cases  gradual  passive  exercises  will  suffice. 
Gentle,  graduated,  passive  motion  carried  to  the  verge  of  being 
painful,  with  the  use  of  electricity,  is  of  great  advantage  in  many 
cases  of  shoulders  stiffened  from  a  slight  degree  of  chronic  joint 
inflammation.  If  the  stiffness  above  alluded  to  is  the  result  of  the 
fixation  due  to  muscular  spasm,  forcible  passive  motion  will  be  of 
no  use,  as  the  reflex  spasm  will  reappear  after  the  effect  of  the 
anaesthetic  has  passed  away,  as  long  as  the  disease  of  the  joint 
remains. 

Local  applications  to  the  joint  are  to  be  used  at  the  shoulder- 
joint  for  the  same  reasons  and  indications  as  to  other  articulations. 

On  the  whole  the  results  of  the  conservative  treatment  of 
shoulder-joint  disease  are  satisfactory  except  in  the  case  of  persons 
whose  general  condition  is  decidedly  bad.  The  great  freedom  of 
movement  of  the  scapula  allows  many  arm  motions  to  take  place 
without  any  movement  of  the  head  of  the  humerus  in  the  glenoid 
cavity,  so  that  it  is  easy  to  secure  almost  complete  rest  to  the 
affected  joint. 

Excision  of  the  SJioidder -Joint. — Dr.  Charles  White  performed  the 
first  excision  of  the  shoulder-joint  for  disease,  in  Manchester,  Eng- 
land, April  14th,  1768.  According  to  the  records  of  Guy's  Hospital 
Reports,  the  shoulder-joint  is  diseased  in  only  one  per  cent  of  all 
^  the  cases  of  diseased  joints.  There  is  a  mortality  from  the  opera- 
tion of  about  15  to  18  per  cent,  and  deaths  from  shoulder-joint  am- 
putations are  estimated  at  '^'j  per  cent  in  amputations  for  all  cases. 

From  a  study  of  statistics,  certain  valuable  facts  are  discovced. 
A  partial  excision  of  the  shoulder  is  more  fatal  than  a  complete 
excision.  The  most  favorable  age  for  operation  appears  to  be  from 
10  to  15,  and  from  15  to  20;  the  least  favorable  being  from  5  to  10 
years.  Those  cases  do  best  after  an  excision  in  which  the  disease 
has  run  a  long  course  of  several  months  or  years;  the  most  un- 
favorable period  for  excision  being  after  the  disease  has  existed 
for  from  three  to  six  months.  The  disease  is  rather  uncommon  in 
young  children,  consequently  excisions  are  not  frequently  per- 
formed in  childhood.  The  prognosis  after  this  operation  is  good,  as 
28 


454 


OR  THOPEDIC  S  UKGER  V. 


regards  usefulness  of  the  arm;  but  a  stiff  joint  should  be  avoided. 
The  movements  of  the  arm  are  usually  impaired  in  abduction  and 
rotation ;  due  to  the  injury  done  the  deltoid,  and  the  cutting  of  the 
attachments  of  the  rotators  of  the  humerus.  The  average  short- 
ening of  the  arm  after  excision  is  about  one  and  one-quarter  inches. 
The  many  complicated  incisions  which  have  been  in  use  from 
time  to  time  for  excision  of  the  shoulder-joint,  have  given  way  to 
the  anterior  longitudinal  incision  (Fig.  380).  This  incision  is  made 
beginning  at  the  anterior  border  of  the  acromion  close  to  its  artic- 
ulation with  the  clavicle,  and  running  vertically  downward  from 
two  to  four  inches,  dividing  the  deltoid  muscle  and  reaching  the 
capsule  of  the  joint,  or  the  periosteum  of  the  humerus.  The  peri- 
osteum is  divided  with  a  bone  knife,  inserted  along  the  inner  border 


Fig.  380.  h  iG.  381. 

of  the  bicipital  groove.  The  arm  is  rotated  both  outward  and 
inward,  and  the  periosteum  and  muscular  attachments  are  removed 
as  they  appear.  The  head  can  be  removed  with  the  keyhole  or 
the  chain  saw,  removing  as  much  of  the  bone  as  is  diseased.  The 
method  of  Oilier  (Fig.  381)  differs  from  that  just  described  in  having 
a  cross  incision  running  outward  from  the  top  of  the  longitudinal 
incision,  which  is  begun  at  the  coracoid  process,  and  is  carried 
downward  and  outward,  in  the  direction  of  the  fibres  of  the  del- 
toid. The  operation  is  performed  subperiostially  and  by  the  larger 
incision  the  head  of  the  bone  may  be  thrown  out  of  the  wound 
and  thus  sawed  off.  In  after-treatment,  very  good  fixation  can  be 
obtained  by  bandaging  the  arm  to  the  side,  with  a  thick  pad  be- 
tween the  body  and  the  inner  side  of  the  arm. 

Plaster-of-Paris  dressing  around  the  arm  and  chest  affords  the 
best  fixation;  and  after  the  need  of  complete  fixation  is  passed,  a 
sling  answers  every  purpose. 


SHOULDIiR,    /■:/./!()  IV,    AND    IVh'/S'f  /o/.V'fS.  435 

Passive  moticMi  of  tlu:  joint  should  he  coniinenced  as  soon  as 
possible  after  the  operation,  if  it  is  desired  U)  secure  a  movable 
joint;  but  the  sur<jeon,  in  that  way,  runs  the  risk  of  making  a  flail 
joint,  inasmuch  as  but  little  of  the  ligamentous  structure  has  been 
preserved,  and  ankylosis  of  the  shoulder  is  of  comparatively  slight 
inconvenience  on  account  of  the  m(^bility  which  the  shoulder  blade 
possesses,  so  that  passive  motion  should  not  be  begun  too  early 
and  in  many  cases  should  not  be  undertaken  at  all. 

DlSK/VSES    OK   THE    ELliOW. 

A  subacute  synovitis  of  the  elbow  is  not  an  uncommon  occur- 
rence after  a  blow  or  sprain.  The  symptoms  are  pain,  swelling 
from  the  effusion  within  the  joint,  and  stiffness.  The  disease  con- 
tinues several  weeks  or  months,  and  may  gradually  subside,  but  is 
liable  to  leave  considerable  impairment  of  motion. 

Purulent  synovitis  may  appear  in  this,  as  in  other  joints,  from 
the  usual  exciting  causes,  and  presents  the  same  characteristics. 

An  ostitis  frequently  follows  an  injury  to  the  joint,  but  in  many 
cases  appears  with  no  apparent  cause,  and  usually  occurs  in  young 
children.  The  disease  may  begin  with  pain,  but  this  is  not  severe, 
and  often  is  entirely  absent.  Limitation  of  extension  of  the  fore- 
arm is  a  constant  and  early  symptom,  motion  in  this  direction 
being  distinctly  restricted  when  flexion,  pronation,  and  supination 
are  free.  A  slight  increase  of  surface  temperature  is  usually  found, 
but  its  absence  does  not  exclude  the  disease.  Careful  examination 
will  reveal  a  slight  amount  of  sw^elling  even  at  this  stage  of  the 
affection,  shown  by  fulness  and  thickening  on  either  side  of  the 
triceps,  and,  looking  at  the  elbow  from  behind,  ths  joint  appears 
broader  than  normal.  As  in  other  joints,  wasting  of  muscles  oc- 
curs rapidly,  and  in  severe  forms  of  the  disease  is  very  great,  espe- 
cially in  the  forearm. 

As  the  disease  progresses,  the  stiffness  increases,  motion  in  other 
directions  is  restricted  and  resisted  by  muscular  spasm,  and  the 
joint  is  held  at  an  angle  of  about  140°.  Starting  pains  may  be 
added  to  the  other  symptoms,  and  become  the  source  of  great 
discomfort.  The  whole  joint  becomes  involved  in  the  swelling, 
the  enlargement  assuming  a  fusiform  shape. 

The  swelling  sometimes  becomes  enormous,  as  in  the  case  shown 
in  the  figure.  The  skin  becomes  riddled  with  sinuses,  the  tuber- 
cular infection  attacks  the  soft  parts,  and  the  whole  arm  becomes 
a  pulpy,  granulating  mass.  This  occurs  in  neglected  cases  of  elbow 
disease,  and  also  as  the  result  of  relapses  after  excision  of  the 
joint. 


436 


ORTHOPEDIC  SURGERY. 


As  in  the  other  joints,  an  accurate  diagnosis  between  synovitis 
and  ostitis  is  not  to  be  made. 

The  prognosis  in  tuberculous  disease  of  the  elbow  is  not  favora- 
ble for  re-establishment  of  motion,  unless  the  affection  is  treated  at 


/;!•      J 


Fig.  382. — Advanced  Tubercular  Disease  of  the  Elbow. 

a  very  early  stage.  The  joint  is  so  complicated  that  the  disease 
involves  a  large  and  comparatively  widespread  surface  of  synovial 
membrane  before  its  presence  is  discovered.' 

CJironic  rheimiatic  arthritis  of  the  elbow,  in  its  course  and  symp- 


^^yH.jir^*sr«Fw^i5^P7K»J?V 


~"^1^ 


I IG.  383. — Enlargement  of  the  Elbow  in  a  Case  of  Spinal  Arthropathy.      (Morrant  Baker.) 

toms,  does  not  differ  from  the  same  disease  in  the  shoulder.  It  is, 
however,  a  less  frequent  seat  of  the  affection,  and  is  one  of  the 
joints  least  liable  to  be  affected  alone. 

Urethral  arthritis  is  very  prone  to  be  located  in  the  elbow ;  in 
this  respect,  perhaps,  ranking  second  to  the  knee  only.  A  stiff 
joint,  held  in  flexion,  is  the  usual  result,  unless  treatment  is  early 
and  efificient. 


SHOULDI'.R,   K/JIOIV,   AND    IV A' /ST  JO/ NTS.  437 

Syphilitic  disease  of  the  elbow  is  sp(jkcn  of  by  Howard  Marsh  as 
occurrfng  in  the  form  of  ^^ummatous  infiltration  of  the  pcri-articuhir 
tissues  and  effusion  into  the  synovial  cavity.  Under  the  influence 
of  iodide  of  potash  these  cases  may  improve  rapidly. 

Charcot's  disease,  in  the  elbow  does  not  differ  in  any  way  from 
that  affection  as  manifested  in  the  other  joints. 

Stijfness  of  the  elbow  is  an  ^iffection  often  found  disassociated 
with  the  signs  of  active  disease.  It  results  from  fracture  with  the 
formation  of  adhesions  or  the  displacement  of  some  of  the  bony 
parts  of  the  joint;  from  synovitis  with  adhesions  of  the  joint  sur- 
faces, and  at  times  even  from  very  slight  grades  of  synovitis;  and 
also  results  from  chronic  arthritis  of  a  tuberculous  or  rheumatic 
type  which  has  caused  destruction  of  the  joint  surfaces  and  fibrous 
or  bony  ankylosis. 

Treatment. — It  has  already  been  hinted  that  the  treatment  of 
serious  elbow-joint  disease  is  not  attended,  as  a  rule,  by  very  satis- 
factory results. 

Simple  synovitis  recovers  usually  under  fixation,  which  is  either 
given  by  fixation  splints,  internal  angular  or  external  angular 
splints,  or  lateral  splints  to  which  the  arm  is  strapped  or  bandaged. 
These  can  be  made  of  tin  or  pasteboard,  reinforced  with  iron  or 
wire  (telegraph  wire)  or  wood,  and  should  be  fitted  to  the  arm  bent 
to  a  right  angle.  Compression  can  be  given  by  surrounding  the 
joint  with  cotton  and  bandaging  it  with  an  elastic  rubber  bandage. 
In  time,  fixation  by  splints  can  be  discontinued,  and  the  support  of 
a  sling  alone  relied  on,  with  passive  exercises  and  massage.  In 
small  children,  pasteboard  splints  give  enough  fixation  for  practical 
purposes,  even  in  very  acute  cases. 

When  chronic  synovitis  or  suspected  ostitis  is  to  be  treated, 
somewhat  more  permanent  fixation  is  demanded.  This  is  best 
furnished  by  plaster  of  Paris,  which  can  be  worn  for  some  weeks 
and  then  be  replaced  wath  little  disturbance  of  the  joint.  The 
fre4uent  readjustment  of  splints  is  objectionable  in  a  sensitive 
joint. 

In  any  event,  a  sling  is  to  be  carefully  Avorn  which  shall  support 
the  hand  and  wrist  as  well  as  the  arm,  and  whatever  apparatus  is 
used,  it  is  essential  to  remember  that  the  elbow  should  be  flexed  to 
a  right  angle,  for  if  ankylosis  occurs  in  any  other  position,  a  useful 
arm  is  not  obtained.  The  natural  position  assumed  by  the  dis- 
eased elbow%  it  has  been  stated,  is  at  an  angle  of  140°. 

Fixation  of  the  elbow  is  indicated  for  a  long  time,  and  at  the  end 
a  certain  amount  of  ank3dosis  is  almost  sure  to  result,  especially 
in  the  severest  cases.  If  the  disease  progresses,  it  is  of  little  use 
to    continue   conservative    treatment;    but    one   must    proceed   to 


438 


ORTHOPEDIC  SURGERY. 


arthrectomy,  or  better  yet,  excision,  before  amputation  becomes 
the  only  measure  holding  out  any  prospect  of  relief. 

When  the  joint  is  fixed  by  muscular  spasm  at  an  angle  greater 
than  a  right  angle,  it  will  often  be  found  possible  to  rectify  this  by 
the  application  of  a  fixation  bandage  to  the  arm  in  its  malposition. 
This  so  quiets  the  muscular  irritation  that  in  two  or  three  weeks 
it  may  easily  be  bent  up  a  little  and  by  the  application  of  a  suc- 
cession of  bandages  it  may  often  be  brought  into  a  right-angled 
position  without  the  use  of  the  least  force. 

Forcible  straightening  of  an  ankylosed  arm  is  sometimes  useful. 
If,  however,  the  ankylosis  is  firm,  but  little  permanent  motion  can 
be  obtained  in  this  way. 

Appliances  for  gradually  rectifying  the  ankylosis  have  been  used 


Fig   384, 


Fig.  385. 
Figs.  384,  385, 


Fig.  386. 
-Apparatus  for  Correction  in  Ankylosis  of  Elbow. 


and  are  of  value  in  slight  cases;  in  severe  cases,  however,  they  give 
but  little  relief. 

The  value  of  elastic  tension  in  correcting  fibrous  ankylosis,  has 
been  shown  by  Dr.  Louis  A.  Weigel,  of  Rochester,  who  has  devised 
an  ingenious  appliance  for  the  application  of  elastic  force  to  grad- 
ually stretch  the  adhesions  of  the  elbow." 

Excision  of  the  elbow  is  perhaps  indicated  earlier  in  the  course 
of  the  disease  than  is  the  case  in  any  other  of  the  larger  joint  ex- 
cisions. After  infancy  is  passed,  operative  interference  is  indicated 
wherever  it  is  clear  that  under  expectant  treatment  the  disease  is 
growing  worse.  Under  these  conditions,  the  results  are  not,  as  a 
rule,  altogether  satisfactory,  but  if  the  disease  is  allowed  to  go  on, 
the  elbow-joint  becomes  so  hopelessly  disorganized  that  amputa- 
tion becomes  necessary.  There  are  no  reliable  statistics  dealing 
with  the  results  of  the  operation,  except  those  of  Culbertson,  re- 

'  New  York  Med.  Journal,  June  i6th,  1888. 


SI/()U/J)/':h\    I'J.noW,  AND    WRIST  JOINTS. 


439 


lating  chiefly  to  o])cr;iti()ns  before  ,'uitiseptic  surgery  came  into  use. 
Of  290  cases  which  recovered  when  complete  excision  of  the  joint 
had  been  performed,  32  were  perfect  and  196  useful.  Oilier,  in  a 
series  of  50  cases  since  i<S76,  has  had  no  deatii  attributable  to 
operation. 

Excision  is  also  indicated  for  ankylosis  in  faulty  position,  as 
when  the  elbow  is  fixed  in  a  positir)n  of  much  more  than  a  right 
angle  or  very  sharply  flexed.  Of  the  very  many  incisions  advo- 
cated for  excisions  of  the  elbow,  the  longitudinal  incision  of  Lan- 
genbeck's  periosteal  method  is  the  one  most  generally  used,  and 
probably  the  most  serviceable.  The  forearm  is  slightly  flexed,  and 
the  incision,  about  3^  inches  long,  is  made  a  little  to  the  inner  side 


Fig.  387. — Langenbeck's  Incision. 


Fig.  3S8. — Ollier's  Incision. 


of  the  median  line  of  the  triceps  and  ulna  and  is  carried  down  to 
the  bone  throughout  its  entire  length.  The  inner  edge  of  the 
divided  periosteum  is  raised  from  the  ulna  With  the  corresponding 
half  of  the  tendon  of  the  triceps,  and  the  dissection  is  continued 
with  the  knife  close  to  the  bone,  toward  the  internal  condyle. 
Much  care  must  be  taken  to  preserve  the  connection  between 
the  periosteum,  the  muscular  attachments,  and  the  internal  lateral 
ligaments.  A  similar  dissection  should  then  be  made  upon  the 
outer  side  with  the  same  precautions.  The  humerus  is  dislocated 
backward  through  the  wound  and  sawed  off  wherever  it  may  be 
necessary.  In  other  cases  it  may  be  advisable  to  use  the  key-hole 
or  chain  saw,  and  as  far  as  may  be  necessary,  the  ulna  is  cleared 
and  sawed  through,  the  head  of  the  radius  being  removed  with  the 
saw  or  bone  forceps. 


440 


ORTHOPEDIC  SURGERY. 


The  incision  of  Oilier,  shown  in  Figure  388,  is  calculated  to  do 
less  injury  to  the  soft  parts.  It  is  commenced  two  inches  above 
the  top  of  the  olecranon  at  the  outer  side  of  the  arm,  involving  the 
skin,  when  it  is  brought  down  to  the  epicondyle,  then  downward 
and  inward  to  the  olecranon,  and  carrying  the  knife  to  the  bone, 
it  is  carried  downward  along  the  inner  side  of  the  posterior  aspect 
of  the  ulna  for  one  or  two  inches.  The  rest  of  the  operation  is 
performed  in  the  same  way  as  the  other. 

In  certain  cases,  where  sinuses  exist,  it  may  be  better  to  adopt 
some  informal  method  of  operation  which  will  be  suggested  by  the 
direction  and  location  of  the  sinuses,  or,  perhaps,  abscesses. 

The  after-treatment  is  similar  to  that  of  other  excisions ;  com- 
plete rest  to  the  joint  and  fixation  in  a  right-angled  position.  This, 
at  first,  can  be  best  obtained  by  the  use  of  a  plaster-of-Paris  splint 
applied  outside  of  a  large  antiseptic  dressing.  Later,  in  the  course 
of  the  convalescence,  bracketed  tin,  or  wooden  splints  may  be  of 
use ;  or,  if  one  desires,  the  original  plaster-of-Paris  splint  may  be 
bracketed  with  strips  of  iron. 

The  average  duration  of  the  stay  in  the  hospital  of  Dr.  Hodges' 
cases  (1852-1860)  was  five  and  one-half  months.  Dr.  Beach  re- 
ported cases,  covering  the  years  to  1877,  in  which  the  patients 
spent  but  two  months  under  treatment.  The  cases  from  1877  to 
1887  spent  in  hospital  treatment — which  means  until  the  wound  is 
almost  healed  and  the  support  to  the  joint  is  dispensed  with — 
about  one  month  and  a  half,  only.  The  after-treatment  is  shorter, 
and  more  is  accomplished,  because  of  a  better  knowledge  of  wound 
treatment. 

In  excision  for  elbow  disease,  as  a  rule,  ankylosis  is  aimed  at  as 
the  best  possible  result,  so  that  passive  motion  is  not  to  be  consid- 
ered ;  if,  however,  the  operation  is  performed  in  adults  for  ankylo- 
sis, and  the  ligaments  have  been  in  a  measure  fairly  preserved  dur- 
ing the  operation,  it  m.ay  be  advisable  to  begin  passive  motion 
after  a  moderate  degree  of  firmness  in  the  tissues  has  been  reached, 
as  there  is  but  little  danger  of  a  flail  joint,  and  it  is  reasonable  to 
expect  that  a  certain  degree  of  motion  at  the  joint  might  thus  be 
obtained. 

Arthrectomy. — In  place  of  a  formal  excision,  the  elbow  can  be 
incised,  and  all  tuberculous  tissue  dissected  out  and  the  bone 
curetted.  This  is  a  procedure  especially  useful  in  children,  and  it 
offers  some  hope  of  drainage  and  relief  in  cases  where  the  disease 
is  too  extensive  to  permit  a  formal  excision.  The  operation  of 
arthrectomy  is  considered  in  detail  in  speaking  of  tumor  albus. 


SIIOULDICN,    I'lIJlOlW  AND    WNJST  JOINTS.  441 

Diseases  of  'iiii-;  Wkist. 

Ostitis  and  synovitis  of  the  wrist-joint  arc  fouiul  as  the  result  of 
sprains  and  as  the  local  exprcs\sion  of  a  tubercular  condition.  The 
signs  are  the  same  as  in  the  other  joints. 

If  the  disease  is  advanced,  deformity  and  swelling  will  be  added 
to  the  other  signs.  The  hand  is  held  flexed  on  the  forearm  at  an 
angle  of  120  to  130  degrees,  and  this  position  is  fairly  constant. 
Swelling  appears  first  in  the  depressions  between  the  tendons. 
Later,  measurement  will  show  the  joint  to  have  increased  in  cir- 
cumference, and  there  is  a  fulness  of  outline,  especially  on  the 
dorsal  surface,  and  in  destructive  disease  the  swelling  extends  up 
on  the  forearm  and  down  on  the  hand.  Suppuration  is  very  liable 
to  occur,  and  the  course  of  the  disease  is  usually  long  and  slow. 

In  the  matter  of  diagnosis,  it  may  be  added  that  swelling  is 
always  present,  and  that  with  the  wasting  of  the  muscles,  the  heat, 
and  the  limitation  of  motion,  it  makes  up  the  clinical  picture  of  the 
disease. 

Tenosynovitis  is  characterized  by  pain  on  the  motion  of  certain 
fingers,  with,  perhaps,  a  sensation  of  rubbing  or  creaking  in  the 
affected  tendons.  Tender  points  are  present  in  the  course  of  these 
tendons.  In  the  superficial  tendons  of  the  wrist,  some  distention 
of  the  synovial  tendinous  sheath  can  be  seen. 

Chronic  Arthritis  Deformans. — The  wrist  is  a  common  seat  of 
this  affection,  with  the  ordinary  symptoms  of  pain,  swelling,  stiff- 
ness, creaking,  etc.  When  deformity  has  occurred,  the  wrist  is 
generally  flexed,  and  the  distal  ends  of  the  radius  and  ulna  are 
enlarged  and  project  backward.  Frequently  the  hand  is  adducted, 
this  often  being  associated  with  a  similar  distortion  of  the  fingers. 

The  wrist  is  one  of  the  joints  liable  to  the  attacks  of  urethral 
arthritis. 

Urethral  arthritis  and  arthritis  deformans  at  the  wrist  should  be 
treated  on  the  principles  already  indicated  for  these  affections. 

In  ostitis  of  the  wrist-joint,  fixation  is  strongly  indicated,  and  it 
is  most  easily  obtained  by  the  application  of  anterior  and  posterior 
common  wooden  splints  and  carrying  the  arm  in  a  sling.  Plaster 
of  Paris  forms  a  more  permanent  dressing,  and  is  equally  comfort- 
able. 

The  conservative  treatment  of  disease  oi  the  wrist  must  not  be 
dismissed  without  a  mention  of  the  great  benefit  often  to  be  de- 
rived from  compression  and  fixation  together.  This  is  obtained  in 
the  Gamgee  dressing  so  often  alluded  to.  Not  only  in  ostitis,  but 
in  teno-synovitis  and  simple  sprained  Avrist,  this  method  is  of  very 
great  value.     As  a  rule,  the  active  symptoms  subside  when  rest  is 


442 


ORTHOPEDIC  SURGERY. 


furnished  to  the  diseased  joint;  but  the  quiescence  of  the  disease 
is  another  matter  and  requires  a  long  time.  The  great  extent  and 
free  communication  of  the  synovial  sacs  of  the  wrist,  make  the  dis- 
ease an  extensive  one  when  located  there,  and  one  which  requires 
a  long  period  of  rest  to  effect  a  cure. 

Excision  of  the  joint  is  indicated  in  the  severest  cases,  or  in 
those  which  progress  badly  under  conservative  treatment.  Disease 
of  the  wrist-joint,  forms  about  4  per  cent  of  all  cases  of  joint  dis- 
ease according  to  the  reports  of  Guy's  Hospital.  In  a  series  of  79 
cases  of  excision  of  the  wrist,  the  results  in  24  per  cent  were 
worthless,  46  per  cent  secured  useful  limbs,  and  in  8  per  cent  per- 
fect results  followed  the  operation.  In  this  series  of  cases  both 
partial  and  complete  excisions  are  included.  Gross  gives  in  his 
tables  a  mortality  of  about  11.7  per  cent  for  excisions,  and  12.8  per 
cent  for  amputations  of  the  forearm.  Oilier  reports  seventeen  re- 
sections of  the  wrist-joint  in  which  the  results  were  excellent ;  sub- 
sequent amputation  was  needed  in  none,  and  all  recovered  with 
useful  hands,  being  able  either  to  write  or  to  carry  out  light  work,, 
and,  in  some  cases,  to  lift  weights.  Motion  at  the  finger-joints  and 
at  the  wrist  became  quite  free.  Bidder '  writes,  after  investigating 
a  number  of  cases,  that  the  normal  power  of  the  hand  can  never 
be  restored  after  a  resection  in  an  adult.  The  best  result  is  either 
ankylosis  or  limited  motion,  and,  therefore,  as  much  bone  as  pos- 
sible should  be  saved.  Other  things  being  equal,  a  loose  joint 
entails  less  power  in  the  hand  and  fingers.  He  has  collected  a. 
number  of  cases  which  were  observed  from  one  to  two  years  after 
the  operation.  A  most  remarkable  one  is  that  of  Lartgenbeck,  the 
patient  being  able  to  write  and  to  work  at  his  trade,  using  his  hand 
nearly  as  well  as  before  the  operation.  The  case  was  examined  six 
and  a  half  years  after  the  removal  of  the  carpal  bones  and  a  part 
of  the  radius.  The  history  of  eleven  other  patients  is  also  given, 
showing  more  or  less  satisfactory  results.  Bidder's  results  coincide 
in  the  main  with  the  experience  of  Dr.  J.  C.  Warren  in  seven  cases. 

According  to  Culbertson's  tables,£  however,  the  results  in  resec- 
tion at  the  wrist-joint  would  appear  to  be  rather  more  favorable 
than  indicated  by  Bidder.  In  the  table  of  excisions  of  the  wrist 
for  disease,  7.59  per  100  secured  "perfect"  results,  45.57  per  100 
''  useful  "  limbs,  24.03  per  100  "  worthless  "  limbs.  The  average 
period  of  recovery  in  thirty-five  cases  was  nearly  two  and  a  half 
years. 

There  are  three  methods  of  excision  of  the  wrist  in  common  use. 

*  Archiv  f.  klin.  Chin,  1883,  28th  Bd.,  iv.,  p.  822. 

="  Boston  Medical  and  Surgical  Journal,  October  26th,  1882,  p.  388. 

3  Transactions  American  Medical  Association,  1876.     Supplement  to  vol.  xxvii. 


SHOUL/)KA\   KLh'OlV,  AND    WRIST  JOINTS. 


AAl 


The  method  of  Lister  is  performed  by  a  radial  and  dorsal  incision 
(Fig.  389).  The  radial  incision  commences  at  tiic  middle  of  the 
dorsal  aspect  of  the  radius  at  the  level  of  the  styloid  processes. 
It  is  directed  toward  the  inner  side  of  the  metacarpo-phalanj^eal 
articulation  of  the  thumb,  and  on  reaching  the  radial  border  of 
the  second  metacarpal  bone  it  is  carried  downward  longitudinally 
for  half  the  length  of  the  bone.  The  soft  parts  are  detached  from 
the  bones  with  the  periosteal  elevator  or  the  blade  of  the  knife, 
and  the  radial  artery  is  thrust  somewhat  outward.  The  soft  parts 
on  the  ulnar  side  are  dissected  up  as  far  as  is  practicable,  while  the 
extensor  tendons  are  relaxed  by  bending  back  the  hand.  The  knife 
is  then  entered  on  the  inner  side  of  the  arm  for  the  ulnar  incision- 
two  inches  above  the  end  of  the  ulna,  and  is  carried  downward  in 


mm^ 


Fu;.  389. 


KiG.  390. 


a  straight  line  as  far  as  the  middle  of  the  fifth  metacarpal  bone 
at  its  palmar  aspect.  The  tendon  of  the  extensor  carpi  ulnaris  is 
cut  at  its  insertion  into  the  fifth  metacarpal  and  dissected  up  from 
its  groove  in  the  ulna,  while  the  tendons  of  the  extensors  of  the 
fingers  with  the  radius  are  left  undisturbed.  The  anterior  surface 
of  the  ulna  is  cleared  by  cutting  close  to  the  bone.  The  anterior 
ligament  of  the  wrist-joint  is  divided  and  the  junction  between  the 
carpus  and  the  metacarpus  is  cut,  the  former  being  extracted 
through  the  ulnar  incision  by  bone  forceps  and  the  use  of  the  knife. 
If  the  hand  is  everted,  the  articular  heads  of  the  radius  and 
ulna  will  protrude  at  the  ulnar  incision,  and  as  much  as  may  be 
necessary  is  then  removed.  The  metacarpal  bones  are  also  pro- 
truded and  dealt  with  in  the  same  way.  The  articular  surface  of 
the  pisiform  bone  is  cut  off  and  the  trapezium  is  dissected  out= 
The    operation    may,    however,   be    performed    by    a    long,    single 


444 


ORTHOPEDIC  SURGERY. 


dorsal  incision  (a  method  identified  with  the  name  of  Langenbeck 
Fig.  390),  which  should  begin  at  the  centre  of  the  ulnar  border  of 
the  metacarpal  bone  and  the  index  finger,  and  be  carried  upward 
to  the  middle  of  the  dorsal  surface  of  the  epiphysis  of  the  radius, 
and  dissected  down  to  the  bone.  The  sheaths  of  the  tendons  are . 
lifted  with  the  periosteum  and  carried  to  the  radial  side  of  the 
long  incision;  the  hand  is  flexed  and  the  articular  surface  of  the 
upper  row  of  carpal  bones  is  exposed.  The  ends  of  the  radius  and 
ulna  may  be  denuded  and  thrust  through  the  wound  and  sawed 
off  in  the  usual  way.  Here,  as  in  other  excisions,  informal  methods 
of  operating  may  be  necessary  on  account  of  the  situation  of  ab- 
'scesses  and  sinuses.  The  operation  is  indicated  where  -expectant 
treatment  has  failed,  but  the  joint  is  so  easily  fixed  and  so  accessi- 
ble, that  mechanical  treatment  works  to  good  advantage.  Opera- 
tion is  attended  with  so  much  deformity  of  the  wrist  and  such 
doubtful  results  on  account  of  the  very  extensive  surface  of  the 
serous  membrane  that  excision  should  not  be  lightly  undertaken. 

The  after-treatment  is  simple,  because  the  hand  can  be  kept  so 
easily  at  rest  upon  a  palmar  splint ;  but  any  form  of  splint  may  be 
applied  which  will  afford  permanent  and  efficient  fixation. 

In  children  excision  should  be  done  only  in  very  severe  cases,  or 
when  conservative  treatment  has  failed.  As  in  ankle-joint  excision 
the  whole  of  every  diseased  carpal  bone  should  be  removed. 


CHAPTER   XII. 

DISEASES    OF   THE    SACRO-iLIAC   AND   OTHER 

JOINTS. 

Diseases  of  the  Sacro-iliac  Joint. — Diseases  of  the  Phalangeal  Articulations. 
Diseases  of  the  Temporo-Maxillary  Articulation. — Diseases  of  the  .Sterno- 
clavicular and  Acromio-Clavicular  Joints. — Diseases  of  the  Articulation 
between  the  Pieces  of  the  Sternum. —  Diseases  of  the  Sacro-coccygeal 
Joints. — Diseases  of  the  Symphysis  Pubis. 

Sacro-Iliac  Disease. 

This  affection  is  also  known  as  sacro-coxitis  (Hueter),  sacrar- 
throcace,  and  sacro-coxalgie.  By  sacro-iliac  disease  is  meant  dis- 
ease of  the  sacro-iliac  synchondrosis. 

Disease  of  this  joint,  according  to  most  authorities,  is  a  rare  con- 
dition. It  is  essentially  a  disease  of  young  adult  life,  being  slightly 
more  common  in  men  than  in  women.  Delens  cites  20  cases  in 
which  the  age  ranged  from  18  to  45  years,  and  the  youngest  case 
which  has  come  under  Erichsen's  observation  was  a  patient  14 
years  old.  Poore,  however,  reports  cases  which  he  has  seen  in 
young  children.  The  acute  form  of  the  disease,  which  is  extremely 
rare  and  quite  violent,  runs  its  course  rapidly,  attended  by  high 
fever  and  suppuration,  and  is  apt  to  terminate  fatally  from  exhaus- 
tion. 

The  chronic  form  practically  means  tuberculous  disease,  although 
some  writers  would  classify  these  cases  under  three  heads;  i.e., 
tubercular,  puerperal  (pyaemic),  and  gonorrhoeal  or  urethral,  with 
a  fourth  class  possible,  i.e.,  syphilitic' 

Pathology. — The  pathological  lesions  which  are  found  in  these 
cases  are  not  unlike  those  accompanying  chronic  inflammation  in 
other  joints;  beginning  either  as  a  synovitis  or  as  an  ostitis. 

Etiology. — The  etiology  is,  also,  in  large  part,  similar  to  that  of 
chronic  disease  of  this  type  in  other  joints;  traumatism  and  the 
strain  of  parturition  being  assigned  as  the  commonest  causes. 
Chanvel '  asserts  that  the  affection  is  fairly  common  in  young  cav- 
alry soldiers,  and   assigns   the   exciting   cause    to   the   traumatism 

^  "  Ref.  Hand-book  Med.  Sciences,"  Vol.  vi.,  p  240. 


446 


OR  THOPEDIC  S  UR  GER  V. 


from  the  equestrian  exercise,  this  joint  being  called  upon  to  sup- 
port the  weight  of  the  trunk.  Gonorrhoea,  by  extension,  is  also 
said  to  be  an  exciting  cause. 

Symptoins.—\n  the  early  part  of  the  disease,  such  symptoms  as  a 
slight  abdominal  distress,  difficulty  in  micturition  or  in  evacuation 
of  the  bowels,  easy  fatigue,  a  feeling  of  indisposition,  etc.,  are  often 
present,  and  as  the  disease  progresses,  more  pronounced  signs 
appear. 

Pain  is  nearly  always  present,  which  may  vary  much  in  intensity. 
It  is  made  worse  by  standing,  and  almost  always  relieved  by  lying 
down.  It  is  also  apt  to  be  more  severe  at  night,  and  is  increased 
by  pressure  upon  the  trochanters  or  wings  of  the 
ilia.  The  pain  varies  in  situation,  and  maybe  re- 
ferred to  the  course  of  the  sciatic  nerve.  Sensi- 
tiveness upon  pressure  over  the  joint  is  a  com- 
mon symptom,  and  this  may  be  developed  over 
the  anterior  part  of  the  joint  by  palpation  through 
the  rectum. 

Some  swelling,  or  a  boggy  feeling,  is  usually 
present  about  the  articulation,  and  if  it  goes  on 
to  abscess  formation,  the  fluctuating  swelling  may 
present  at  almost  any  point,  either  directly  back- 
ward, into  the  lumbar  region,  or  it  may  become 
intra-pelvic,  in  which  case  it  may  appear  in  the 
groin,  as  a  psoas  abscess,  or  point  in  the  ischio- 
rectal fossa,  or  at  either  of  the  sacro-sciatic 
notches.- 

Limping  is  practically  always  present. 
The  position  of  the  body  in  walking  or  stand- 
ing is  fairly  characteristic,  the  weight  of  the 
trunk  being  thrown  upon  the  well  foot,  while 
the  other  leg  hangs  down ;  this  exerts  a  slight  extension  by  its 
weight.  In  walking  the  gait  is  very  cautious,  all  jar  is  avoided, 
and  hence  the  toe  is  largely  used  instead  of  the  flat  of  the  foot  on 
the  diseased  side. 

Atrophy  of  the  muscles  of  the  leg  upon  the  affected  side  is  usu- 
ally present,  and  is  seen,  as  in  other  chronic  joint  affections,  quite 
early  in  the  disease. 

Diagnosis. —  Sacro-iliac  disease  has  been  mistaken  for  sciatica, 
but  aside  from  the  fact  that  the  latter  is  usually  found  later  in  life, 
the  pains  are  not  relieved  by  the  recumbent  position.  According 
to  Barwell '  a  suspicion  at  least  may  be  aroused  as  to  the  condition 


Fig.  391.— Attitude  in 
Sacro-Iliac  Disease. 


"  Internal.  Encyclo.  Surg.,"  Vol.  iv.,  p.  400. 


DISEASES  OF   THE  SACh'O-/ fJ/lC  AND  OT// /■:h'  JO/XTS.    447 

present,  by  prcssinc^f  the  ;inl(.:ri')r  ;il)(lf)tjiin;il  ]jai'ictes  backward, 
which  in  sciatica  produces  no  ])aiii,  while  in  sacro-iliac  (h'sease  it 
frequently  causes  distress. 

In  lumbago  the  pain  is  more  diffuse  and  higher  ujj  than  in  dis- 
ease of  the  sacro-iliac  articulation. 

Inflammation  of  the  psoas  muscle  (psoitis)  more  usually  simu- 
lates hip  disease,  but  it  may  be  mistaken  for  sacro-iliac  disease. 
In  this  there  is  no  tenderness  over  the  joint,  and  the  pain  which 
is  present  is  increased  by  extension  of  the  thigh,  while  flexion 
relieves  it. 

Positive  diagnosis  of  sacro-iliac  disease  from  hip  disease  and 
Pott's  disease  in  the  lumbo-sacral  region  is  at  times-very  difficult 
and  often  impossible,  especially  in  the  class  of  cases  just  referred 
to.  In  hip  disease  all  manipulation  is  resisted  by  muscular  spasm, 
while  in  sacro-iliac  disease,  with  the  iliac  bones  held  firmly,  all 
motions  at  the  hip  are  possible  without  pain.  Also  in  hip  disease 
the  pain  is  never  increased  by  pressure  upon  the  wings  of  the  ilia 
as  is  the  case  in  sacro-iliac  trouble.  In  lumbo-sacral  Pott's  disease 
it  is  at  times  practically  impossible  to  distinguish  it  from  disease  of 
the  sacro-iliac  joint,  but  generally  the  diagnosis  is  easily  made. 
Also  in  spinal  caries  we  have  a  prominence  of  some  of  the  spi- 
nous processes  with  rigidity  of  the  spine  Avhen  motion  is  attempted, 
and  local  tenderness  is  not  present  over  the  sacro-iliac  articulation, 
nor  does  pressing  together  the  ilia  cause  pain. 

Prognosis. — -The  prognosis  in  this  disease  is  at  best  quite  grave. 
Cases  do  recover,  but  it  is  one  of  the  most  chronic  of  joint  affec- 
tions, and  usually  goes  on  to  abscess  formation,  with  prolonged 
suppuration  and  death  either  from  exhaustion,  renal  complications, 
or  secondary  tuberculosis. 

Weller  Van  Hook '  reports  thirty-eight  cases  with  abscess,  of 
which  only  three  recovered. 

Treatment. — The  principles  of  treatment  are  the  same  as  should 
govern  the  care  of  all  chronic  joint  affections.  In  the  acute  stage, 
the  patient  should  be  kept  upon  the  back  in  bed,  with  weight-and- 
puUey  extension  to  the  leg,  and  as  the  acute  symptoms  abate,  he 
may  be  allowed  to  go  about  on  crutches,  with  a  high  sole  upon  the 
well  foot,  the  weight  of  the  other  leg  serving  as  extension.  While 
moving  about,  a  certain  amount  of  comfort  may  be  derived  from  a 
swathe,  either  of  cotton  or  of  adhesive  plaster,  about  the  pelvis, 
which  serves  in  part  to  fix  the  joint. 

In  the  very  beginning  of  the  disease,  the  actual  cautery  has  been 
recommended  as  counter-irritation  in  this  as  in  all  chronic  afTec- 

^  Journal  of  the  American  Medical  Association. 


448  ORTHOPEDIC  SURGERY. 

tions  of  the  joint.  Kolischer  '  recommends  for  local  treatment  the 
injection  of  iodoform  and  calcium  phosphate. 

Where  an  abscess  has  formed,  it  should  at  once  be  laid  open, 
any  diseased  bone  removed,  and  treated  like  any  cold  abscess. 
When  the  abscess  is  intra-pelvic  it  may  be  quite  difificult  to  reach, 
and  Van  Hook  describes  a  very  ingenious  method  for  reaching  and 
draining  the  cavity.  An  incision  is  made  near  the  posterior  part  of 
the  crest  of  the  ilium  on  the  affected  side,  the  tissues  divided  down 
to  the  bone  and  a  piece  of  the  ilium  chiselled  away.  This  brings 
the  joint  within  reach,  and  through  the  opening  any  diseased  bone 
may  be  removed  and  the  cavity  drained. 

In  all  of  these  cases  tonics  and  constitutional  treatment  are  not 
to  be  neglected. 

Phalangeal  Articulations. 

Owing  to  their  exposed  position  to  sprains,  blows,  etc.,  the  pha- 
langeal joints  are  frequently  found  enlarged,  slightly  deformed,  and 
stiff. 

The  hand  is  a  very  common  seat  of  arthritis  deformans,  which 
often  begins  in  one  or  two  joints  of  one  finger,  and  some  time 
elapses  before  it  attacks  the  others.  The  joints  become  much  en- 
larged, and  distortion  usually  occurs  to  the  ulnar  side,  this  adduc- 
tion being  chiefly  in  the  metacarpo-phalangeal  joint.  The  fingers 
become  permanently  distorted,  flexed  or  abducted,  or  both;  the 
second  phalanges  of  the  fingers,  as  well  as  of  the  thumb,  are  usually 
extended,  giving  a  characteristic  appearance  to  the  hand. 

Local  treatment  in  arthritis  deformans  is  of  no  especial  use  when 
the  fingers  are  involved,  and  one  must  depend  upon  the  somewhat 
uncertain  prospect  of  arresting  the  disease  by  general  measures. 

Temporo-Maxillary  Articulation. 

By  far  the  most  common  affection  of  this  joint  occurs  in  chronic 
rheumatic  arthritis,  which  presents  the  same  characteristics  as 
when  occurring  elsewhere  and  which  may  result  in  ankylosis. 

Tube7'culous  disease  may  occur,  secondary  to  disease  of  the  ramus 
or  ear,  but  it  is  rare. 

Subluxations  occur  from  relaxation  of  the  ligaments,  usually  in 
young  people,  and  most  frequently  women.  The  patient  suddenly 
finds  himself  unable  to  close  the  mouth,  and  until  he  has  acquired 
the  method  of  reducing  the  dislocation  himself,  it  must  be  accom- 
plished in  the  routine  way  as  in  the  treatment  of  traumatic  disloca- 

'  "  Ref.  Hand-book  Med.  Sciences,"  Vol.  vi.,  p.  242. 


DISEASES  OF  THE  SACRO-I TJAL'  AND  OT/f/'.h'  JOINTS.     449 

tion.     A   tendency  to   this   accident,   once   cstablislied,    is   usually 
permanent. 

A  blister  applied  over  the  articulati(jn  sometimes  appears  to  have 
a  beneficial  effect,  but  generally  the  affection  becomes  better  and 
worse  independent  of  any  treatment,  local  or  general,  at  times  caus- 
ing a  great  amount  of  discomfort  and  at  other  times  not  being 
noticeable. 

Stcrno-Clavtaila?'  and  Acroinio-Clavicular  Joints. — Enlargement 
of  these  joints  sometimes  occurs  in  persons  accustomed  to  hard 
work  with  their  upper  extremities.  Inflammation  of  the  sterno- 
clavicular articulation,  followed  by  suppuration  and  caries,  is  occa- 
sionally observed,  but  presents  no  unusual  symptoms.  Chronic 
rheumatic  arthritis  may  occur  in  either  of  these  joints,  causing 
pain  and  stiffness,  enlargement,  and  weakness  of  the  upper  extrem 
ity.  The  sterno-clavicular  joint  is  not  an  infrequent  seat  of  metric 
arthritis. 

Articulation  oj  the  first  and  second  Pieces  oj  the  Sternum. — 
Disease  in  this  situation  is  rare,  but  has  been  described  by  Mr. 
Hilton.  The  symptoms  were  pain  about  the  sternum,  especially 
severe  on  forced  or  sudden  respiratory  exertion,  and  great  tender- 
ness over  the  joint.  Recovery  took  place.  Fixation  and  expect- 
ancy are  all  that  can  be  done  for  these  joints. 

Symphysis  Pubis. — Cases  are  recorded  of  chronic  disease  of  this 
joint '  as  well  as  of  its  complete  ossification  in  comparatively  young 
people."" 

Sacro-Coccygeal  Disease. — Disease  of  the  coccygeal  joint  is  very 
rare,  yet  several  well-marked  cases  have  been  recorded.  The  con- 
dition may  be  detected  by  means  of  the  thickening  over  the  joint 
and  pain  upon  motion. 

By  the  rectum,  distinct  grating  of  the  diseased  surfaces  may  be 
felt  when  the  joint  is  moved. 

When  the  joint  is  clearly  involved,  excision  of  t4ie  coccyx  is  the 
best  treatment,  but  when  this  is  not  advisable,  Bryant  ^  suggests  a 
subcutaneous  division  of  the  coccygeal  muscles  by  which  the  joint 
is  allowed  to  rest.  Ankylosis  is  not  a  rare  occurrence,  and  the 
union  may  take  place  with  the  bones  in  almost  any  position. 

'  Holmes'  "  System  of  Surgery,"  vol.  iv. ,  p.  88;  Bryant:  "  Practice  of  Surgery,"  p.  gig. 
^  Otto,  quoted  by  Holmes. 
3"  Practice  of  Surgery,"  p.  gig. 
29 


CHAPTER  XIII. 

CLUB-FOOT. 

Frequency. — Anatomy. — Causation. — Symptoms. — Diagnosis. — Prognosis. — 

Treatment. 

The  term  club-foot  is  popularly  applied  to  a  deformity  charac- 
terized by  an  inversion,  torsion,  and  depression  of  the  front  part 
of  the  foot  with  an  elevation  of  the  heel. 

In  walking  on  a  foot  thus  deformed,  the  weight  of  the  body  is 
borne,  not  by  the  sole  of  the  foot,  but  by  the  outer  side,  and  in 
extreme  cases  by  the  dorsum  of  the  foot. 

The  distortion  is  also  known  as  talipes  equino-varus. 

Other  names  in  use  are  :  "  Reel  "  foot — Pes  contortus. 

German :  Klump-fuss. 

French :  Pied  bot. 

The  deformity  is  either  congenital  or  acquired. 

Frequency. — Club-foot  is  by  no  means  an  uncommon  distortion, 
and  was  mentioned  in  literature  even  in  the  days  of  Homer.' 
Tamplin,  out  of  10,217  cases  of  deformity  treated  at  the  Royal 
Orthopedic  Hospital,  met  with  6,754  club  feet,  of  which  1,780  were 
congenital.  Chaussieur,  out  of  22,923  newly-born  infants,  reports 
37  cases  of  club-foot.  Lannelongue,  out  of  15,229  births  at  tlie 
Paris  Maternity  Hospital,  found  8 ;  and  Duval,  in  1,000  cases  of 
club-feet,  found  574  congenital,  of  which  364  were  males  and  210 
were  females. 

Anatomy. 

The  deformity  is  a  dislocation  inward  of  the  anterior  part  of 
the  foot,  the  dislocation  taking  place  at  the  medio-tarsal  articula- 
tion. All  the  tissues  are  necessarily  affected  by  the  abnormal  posi- 
tion, and  the  skin,  muscles,  tendons,  and  fasciae  are  all  altered. 

In  all  cases  of  congenital  club-foot,  even  in  that  of  a  full-term 
foetus,  the  scaphoid  bone  will  be  found  articulating  with  the  side 
of  the  head  of  the  astragalus  rather  than  with  the  anterior  surface. 
The  articulation  is  also  more  toward  the  under  side  of  the  astrag- 
alus, the  head  of  which  is  thus  uncovered. 

'  "  Iliad,"  i.,  599;    xxi.,  331. 


C/Jf /!-/'-()()'/'. 


451 


The  scaphoid  may  be  so  far  distorted  to  the  side  as  to  articulate 
at  one  end  with  the  tip  of  the  internal  malleolus.  In  one  instance 
in  the  ankle  of  a  full-term  foetus,  dissected  by  the  writers,  a  sepa- 
rate synovial  sac  was  found  between  the  end  of  the  astragalus  and 
the  malleolus.  In  infantile  cases  the  distortions  in  the  shape  of  the 
bones  are  of  little  importance,  as  the  ends  of  the  bones  are  largely 
cartilaginous.  The  position  of  the  tarsal  bones,  is,  however,  not 
the  normal  one.  The  cuneiform  bones  being  intimately  connected 
with  the  scaphoid  follow  the  displacement  of  the  latter,  and  the 
same  is  true  of  the  metatarsal  bones  and  the  phalanges,  so  that 
the  long  axis  of  the  front  of  the  foot  forms  a  right  angle,  or  even 
an  acute  angle,  with  the  axis  of  the  leg.  The  cuboid  is  necessarily 
displaced  to  the  inner  side  and  does  not  articulate  with  the  front 


Fig.  392. — AI,  Malleolus;  ci,  astragalo-scaphoid 
articulation. 


Fig.  393. — Dissection  of  Club-foot,    y,  fibula;  .v,  tibia; 
r,  OS  calcis;  ct,  astragalo-scaphoid  articulation. 


of  the  OS  calcis,  the  facet  of  which  also  inclines  obliquely  to  the 
inner  side. 

In  fully  developed  cases,  and  in  older  children,  or  adults,  there  is 
a  marked  alteration  in  the  shapes  of  the  bones,  not  only  in  the 
astragalus,  but  in  the  os  calcis  and  cuboid.  The  alterations  of  the 
bones  which  have  been  noticed  are  chiefly  in  the  position  and 
shape  of  the  following  bones:  viz.,  the  os  calcis,  cuboid,  astragalus, 
and  scaphoid. 

The  OS  calcis,  by  the  elevation  of  the  tuberosity,  is  drawn  from  a 
horizontal  into  a  position  approaching  the  vertical.  It  is  also  more 
or  less  rotated  on  its  vertical  axis,  so  that  its  anterior  extremity  is 
directed  outward,  and  the  posterior  extremity  inward,  and  thus 
the  anterior  articulating  facet  is  oblique  to  the  axis  of  the  bone. 
The  cuboid  bone  maintains  its  connection  with  the  os  calcis,  but 
follows  the  inward  direction  of  the  anterior  extremity  of  the  foot. 

Astragalus. — There  is  no  rotation  of  the  astragalus  on  the  verti- 
cal axis,  but,  as  has  been  stated,  it  is  depressed  forward  on  its  hori- 
zontal axis,  so  that  only  the  posterior  portion  of  its  superior  artic- 


452 


OR  THOPEDIC  S  URGER  V. 


ular  surface  is  in  contact  with  the  inferior  articular  surface  of  the 
tibia,  and  the  anterior  part  of  its  anterior  facet  projects  beneath  the 
skin  of  the  dorsum  of  the  foot.  Besides  this  displacement,  the 
shape  of  the  bone  is  altered  by  the  twisting  inward  of  the  head 
and  neck,  so  that  the  anterior  articular  surface  looks  inward  instead 


Fig.  394. — ^The  Os  Calcis  in,  a,  child 
of  one  year  with  club-foot;  /;,  normal  new- 
born; c,  new-born  infant  with  club-foot. 


Fig.  395. — Astragalus  and 
Scaphoid  in  Club-foot. 


Fig.  396. — Side  View  Astra- 
galus, Normal  and  in  Club-foot. 


of  forward,  and  the  disposition  of  the  cartilage  at  the  articulating 
surfaces  of  the  head  of  the  astragalus  is  necessarily  altered.  The 
three  cuneiform  and  the  three  metatarsal  bones  being  closely  con- 
nected with  the  scaphoid  are  more  twisted  to  the  inside  than  is  the 
case  with  the  cuboid,  though  the  metatarsals  are  not  all  equally 
drawn  in  the  rotation .  from  without  inward  and  are    spread  out 


Fig.  397. — Astragalus  from  an 
Adult  Club-foot. 


Fig.  39S.— Section  of  Foot  and 
Leg  in  Club-foot. 


Fig.  399. — Section  of  Foot 
and  Leg — Normal. 


something  as  the  branches  of  a  fan,  "in  such  a  way  that  the  anterior 
part  of  the  foot  is  enlarged  more  than  normal.  Besides  these 
alterations  in  the  position  of  the  foot,  others  take  place  secondarily, 
depending  on  pressure  and  the  effect  of  locomotion  on  the  dis- 
torted bones. 

,  The  different  tendons  assume  an  abnormal  direction  and  in  gen- 
eral are  carried  further  to  the  inside  than  is  normal;    this  is  espe- 


C7J//!-F<)()T. 


453 


cially  true  of  the  tibialis  aiiticus,  the  comm(;n  extensor  of  tiic  toes, 
and  the  long  extensor  of  the  great  toe.  Synovial  burs;e  form  on 
the  outer  edge  and  back  of  the  foot,  which  may  become  inflamed 
and  suppurate ;  corns  and  callosities  are  also  formed  on  the  skin, 
from  the  pressure  of  walking.  No  change  has  been  found  in  the 
nerves  or  the  spinal  cord  in  cases  of  club-foot. 

In  extreme  cases  there  may  be  slight  alteration  in  the  shape  of 
the  femur,  and  a  laxity  at  the  knee-joint;  the  tibia  has  also  been 
found  altered,  and  the  same  is  true  of  the  fascia;.  The  muscles 
are  never  found  paralyzed  in  congenital  club-foot,  but  the  con- 
tracted muscles  seem  more  developed  than  the  lengthened  muscles. 


fc 


iV:. 


:V"*^^?te»;^- 


Fig.  400. — Normal  Adult  Astragalus, 


Fig.  401. — Normal  Adult  Astragalus. 


The  muscles  of  the  leg  atrophy  from  disuse,  and  the  leg  is  much 
smaller  and  the  foot  shorter  than  normal. 

Ligaments. — In  addition  to  the  faulty  shape  of  the  bones,  there 
is  a  change  in  the  ligaments  and  fasciae,  and  this  is  not  confined  to 
the  severe  and  most  inveterate  cases,  but  is  always  present.  Not 
only  are  the  plantar  ligaments  and  fasciae  contracted,  but  the  inter- 
nal lateral  and  posterior  ligaments  are  also  contracted. 

Causation. 


The  deformity  is  usually  a  congenital  one,  but  it  may  also  be 
acquired,  after  the  impairment  of  muscular  power  which  takes 
place  in  infantile  paralysis,  and  after  accident.  In  regard  to  the 
etiology  of  congenital  club-foot,  various  theories  have  been  ad- 
vanced in  explanation  of  the  deformity. 

A  popular  idea  is  that  the  distortion  is  due  to  maternal  impres- 
sions, but  no  evidence  in  regard  to  this  has  been  obtained.     Dab- 


454 


ORTHOPEDIC  SURGERY. 


ney '  has  collected  ninety  cases  of  maternal  impressions,  apparently 
causing  deformity.  In  none  of  these  was  club-foot  produced,  and 
it  may  be  assumed  that  at  present  there  is  no  recorded  case  of  the 
developrhent  of  club-foot  by  maternal  impressions. 

Heredity,  both  on  the  part  of  the  father  and  mother,  has  been 
established  without  doubt  in  a  certain  number  of  cases,  but  in  a 
very  large  majority  of  them  no  trace  of  similar  deformity  in  ances- 
tors can  be  found.  Devay  and  Boudin  report  that  more  cases  of 
club-foot  are  found  in  children  from  marriages  of  kin  than  among 
others.  One  case  in  164  births  from  marriages  of  kin,  and  i  case  in 
1,903  of  other  marriages  is  reported. 

The  chief  theories  which  are  advocated  to  explain  the  deformity 
in  uterine  life  are  as  follows:' 

First. — -Abnormal  compression  in  the  uterine  cavity. 
Second. — Retraction  or  paralysis  of  muscles  depending  or  not  on 
lesion  of  the  nervous  system  occurring  in  utero. 

Third. — A    malformation   depending  upon  ar- 
rest of  development  of  the  foot. 

The  first  of  these  explanations  is  as  old  as 
Hippocrates.  Ambroise  Pare  and  Cruveilhier 
maintained  the  same  idea,  except  that  the  latter 
believed  that  a  blow  received  by  the  mother  was 
an  influential  cause,  and  states  that  where  club- 
foot is  single,  the  anterior  foot  in  utero  is  the 
FcEtus  in  Utero.  (Parker.)  one  affccted,  and  where  the  deformity  is  double, 
the  anterior  foot  in  the  uterus  is  affected  to  a  greater  degree. 
Malgaigne  also  maintained  the  same  opinion.  Many  objections 
can  be  brought  forward  against  the  theory  of  mechanical  pressure 
of  the  uterus  as  a  cause  of  the  deformity.  If  uterine  pressure  were 
an  influential  factor,  it  would  be  true  that  prominent  flexed  knees 
would  be  frequent  deformities,  which  are  very  rarely  seen.  The 
normal  rotation  of  the  foot  from  the  primary  inverted  position 
first  held  in  utero  is  not  due  to  muscular  contraction,  as  it  occurs 
at  a  time  when  there  are  no  muscles,  but  it  is  due  to  the  growth 
of  the  parts.  At  an  early  stage  of  uterine  life,  the  feet  are  rotated 
outward,  so  that  the  surface  of  the  thigh  and  the  tibial  border  of 
the  leg  are  pressed  against  the  abdomen,  the  legs  crossing  each 
other  at  their  middle  and  the  limbs  being  flexed  at  the  knees. 
Uterine  pressure  with  the  limb  in  this  position  necessarily  confirms 
the  position  of  equino-varus,  but  the  lower  extremities  alter  their 
position ;  the  thighs  are  drawn  inward  and  rotated,  so  that  the 
anterior  surface  instead  of  the  inner  surface  lies  next  to  the  abdo- 


FiG.  402. — Compression  of 


'  Dabney:  "  Cyclopedia  Diseases  of  Children,"  vol.  i. 


cf.  ir /!-/■•( )()  /'. 


455 


men,  and  the  soles,  instead  of  tlie  router  surfaees  of  the  foot,  are 
pressing  against  the  uterine  wall.  In  favor  of  this  theory,  how- 
ever, may  be  stated  the  fact  that  tlie  leg  is  rotated  outward  at 
birth  in  all  cases  born  with  the  deformity,  h'urthermore,  there  is 
no  evidence  found  of  probable  abnormal  uterine  pressure,  for  an 
absence  of  amniotic  fluid  is  not  found,  as  a  rule,  in  cases  of  birth  of 
infants  with  club-foot,  the  reverse  being  asserted  by  JJuval.  The 
deformity  is  also  noticed  before  the  fourth  or  fifth  month  of  intra- 
uterine life,  at  a  time  when  the  amniotic  fluid  is  in  abundance  and 
when  no  intra-uterine  pressure  is  possible. 

The  theory  of  abnormal  difference  in  the  strength  of  the  leg 
muscles  dependent  or  not  on  disturbances  of  the  central  nervous 
system  has  been  held  by  many  writers.  Morgagni,  Benjamin  Bell, 
and  Delpech  believed  that  the  contraction  of  certain  muscles 
caused  the  deformity,  while  Beclard  believed  the  weakness  of 
other  muscles  was  the  influential  factor.  Confirmatory  of  this 
view  is  the  fact  that  the  deformity  is  often  seen  in  hydrocephalic 
and  anencephalic  foetuses,  and  those  suffering  from  spina  bifida. 
But  this  idea  is  not  supported- by  the  fact  that  in  a  large  majority 
of  cases  no  alteration  of  the  nervous  system  can  be  found.  Out 
of  688  cases  of  congenital  varus  in  the  London  hospitals,  only  2 
were  affected  with  spina  bifida.  Duval,  out  of  574  cases  of  club- 
foot, found  no  other  deformity  present ;  Lannelongue  found  in  78 
cases  of  monstrosities,  27  which  were  free  from  club-foot,  and  in  32 
cases  of  spina  bifida  and  encephalocele  only  4  club-feet  were  seen. 

The  third  theory,  that  of  arrest  of  development  of  the  foot,  is 
the  one  maintained  by  Meckel,  Saint  Hilaire,  Adams,  Hueter  and 
others.  According  to  these  authors,  since  the  feet  are  developed 
normally  at  the  sixth  or  seventh  Aveek,  the  foetus  has  the  sole 
turned  inward,  and  a  permanence  of  this  position  would  give  a 
club-foot. 

Cruveilhier  has  denied  this  anatomical  fact,  but  it  is  maintained 
by  Martin  and  others ;  and  although  this  theory  explains  the  de- 
formity of  varus,  it  is  incapable  of  explaining  that  of  other  varie- 
ties of  congenital  talipes.  This  theory  has  been  modified  so  as  to 
admit,  not  only  the  arrest  of  development  properly  so  called,  but 
the  malformation  of  the  bone  which  forms  the  skeleton ;  an  opinion 
defended  by  Bouvier,  Brocher,  Lannelongue  and  others.  The  con- 
clusion to  be  derived  from  all  this  is  that  it  may  be  said  that  we 
are  entirely  ignorant  of  the  causation  of  club-foot,  and  unable  to 
give  a  reasonably  satisfactory  explanation  of  the  phenomena  of  its 
development. 

The  subject  of  the  causation  of  club-foot  has  been  carefully  in- 
vestigated  anew  by  Parker  and  Shattuck  {Brit.  Med.  Jour.,  1886. 


456  ORTHOPEDIC  SURGERY. 

Vol.  II.,  lo),  Berg  {Archives  of  Medicine,  N.  Y.,  Dec.  ist,  1882),  and 
Scudder  ("  Boylston  Prize  Essay,"  1887,  Boston  Med.  and  Surg. 
Journal,  Oct.  27th,  '87),  but  the  subject  is  still  unsettled,  though 
their  investigations  seem  to  point  to  retarded  rotation  as  the 
immediate  caase  of  the  deformity 

Parker  and  Shattuck  have  called  attention  to  the  fact  that  in 
anthropoid  apes  there  is  an  inward  obliquity  of  the  neck  of  the 
astragalus,  and  yet  no  club-foot  exists  in  these  animals. 

To  confirm  this  fact,  Dr.  E.  G.  Brackett  has  been  kind  enough  to 
examine  the  skeletons  of  several  monkeys  at  the  Boston  Natural 
History  Museum,  and  has  found  that  in  two  skeletons  of  monkeys 
examined  the  angle  of  inclination  of  the  neck  of  the  astragalus  was 
not  over  20°,  and  in  two  others,  30°  and  35°.  The  articular  surface 
faced,  however,  in  each  case,  nearly  directly  forward,  being  set  on 
the  neck  at  an  angle.  The  effect  of  the  inclination  of  the  neck 
was  to  broaden  the  tarsus  at  this  point,  rather  than  to  give  any 
effect  of  talipes.  Although  the  anthropoid  apes  are  not  club- 
footed,  they  are  quadrumana,  the  toe  being  prehensile  and  placed 
obliquely  inward,  instead  of  being  parallel  to  the  axis  of  the  foot. 
One  feature  of  a  varus  distortion  is  present,  and  probably  explains 
the  alteration  in  the  neck  of  the  astragalus.' 

A  marked  divergence  of  the  great  toe,  similar  in  a  measure, 
though  to  a  less  marked  degree,  to  that  seen  in  tlje  anthropoid  apes, 
is  reported  by  travellers  to  be  characteristic  of  the  pure  natives  of 
Annam.  No  dissection  of  feet  of  this  race  has  been  reported,  and 
the  inclination  of  the  axis  of  the  head  of  the  astragalus  is  not  known. 

Symptoms. 

Club-foot  gives  rise  to  great  inconvenience  in  walking.  In  un- 
corrected cases,  however,  the  amount  of  skill  and  agility  patients 
acquire  in  locomotion  is  surprising,  even  though  the  deformity  re- 
mains unchanged.  Bursae  and  callosities  form  over  the  unprotected 
portions  of  the  foot,  and  may  inflame  and  cause  much  discomfort, 
limiting  the  amount  of  the  patient's  activity.  A  laxity  of  the 
knee-joint  is  sometimes  developed  in  consequence  of  club  foot,  and 
some  change  in  the  shape  of  the  femur  and  tibia  and  fibula  occurs. 
No  alterations  of  importance  of  the  pelvis  take  place,  though  there 
is  undoubtedly  a  distortion  of  the  head  and  neck  of  the  femur 
which  causes  an  increased  awkwardness  in  gait. 

Although  club-foot  is  not  an  affection  which  interferes  with 
activity  or  usefulness,  the  deformity  is  so  marked  that  it  is  a  source 
of  great  mental  suffering.    Lord  Byron  presents  a  notable  instance, 

'  R.  W.  Parker  and  Shattuck :    Brit.  Medical  Journal,  May  24th.  1884,  p.  998. 


CLUn-l'OOT. 


457 


and  Talleyrand  is  said  to  have  entered  tlie  cluirch  on  account  of 
this  distortion.  Dicffcnbach  states  that  of  all  the  women  treated 
by  him,  only  one  was  married,  indicating  that  the  deformity  was  a 
great  impediment  to  marriage. 

The  gait  of  these  patients  is  characteristic.  In  double  cases  the 
feet  are  lifted  one  over  the  other  as  a  step  is,  taken,  giving  a  pecu- 
liar appearance,  and  perhaps  suggesting  the  popular  name  of 
"  reel  "  feet. 

The  distortion  presents  an  inward  twist  of  the  foot,  with  a  de- 
pressed position  of  the  outer  edge.  The  tendo  Achillis  is  firm  and 
hard  to  the  touch ;  the  plantar  fascia  will  be  found  short  and  hard 
on  palpation.     The  front  of  the  foot  projects  to  the  inside  of  the 


Fig.  403.— Diagram  Illustrating  the  Inward  Rotation  Fig.  404. ^Severe  Club-foot, 

of  Anterior  Part  of  Foot. 

vertical  axis  of  the  leg,  the  tendinous  end  of  the  os  calcis  is  raised 
and  turned  inward,  the  leg  is  turned  outward,  and  the  head  of  the 
astragalus  and  cuboid  project  under  the  skin.  There  is  usually 
atrophy  of  the  muscles  of  the  leg.  The  external  malleolus  is  prom- 
inent and  the  internal  malleolus  not  readily  felt. 

Diagnosis. 

There  is  no  difTficulty  in  recognizing  the  deformity  of  club-foot. 
In  infancy,  a  true  club-foot  is  sometimes  thought  to  exist  when 
the  trouble  is  simply  a  temporary  spasm  of  the  tibialis  muscles 
which  turn  the  foot  in.  This  passes  away  in  a  short  time  and 
should  occasion  no  anxiety. 

The  deformity  may,  for  practical  purposes,  be  divided  into 
three  classes. 

First. — Where  the  foot  can  be  brought  nearly  into  a  normal 
position  by  manipulation  with  the  hand. 


458 


ORTHOPEDIC  SURGERY. 


Second. — Where  the  axis  of  the  foot  can  be  brought  into  the  Hne 
of  the  axis  of  the  leg,  but  the  foot  cannot  be  brought  to  a  right  angle. 


Fig.  405. — Congenital  Talipes  Varus  in  an  Adult 
26  years  old. 


Fig.  406. — Sole  of  Foot  in  Severe  Adult 
Club-foot. 


Third. — Where  little  alteration  can  be  made  by  manual  manipu- 
lation of  the  foot. 

The  history  of  the  case  establishes  a  diagnosis  between  the  con- 
genital and  non-congenital  forms  of  club  foot.     The  paralytic  form 


Fig.  407. — Contracted 
Plantar  Fascia  in  Talipes 
Equino- Varus. 


Fig.  408. — Resistant  Club-foot. 


Fig.  409. — Congenital  Equino 
Varus  Showing  Promuience  of 
Head  of  Astragalus. 


can  be  recognized  by  the  evidence  of  paralysis  of  the  muscles  on 
the  anterior  and  external  surface  of  the  leg.  Paralysis,  it  may  be 
added,  is  the  only  common  cause  of  acquired  club-foot.  The 
severity  of  cases  of  club-foot  cannot  be  determined  always  by  the 
apparent  distortion.  Cases  resembling  each  other  in  outward  ap- 
pearance, may  prove  less  or  more  dififilcult  of  treatment.     As  a  rule, 


CJAJJi-l'OOT. 


459 


however,  it  may  be  said  that  the  youn^^er  the  patient,  the  less  resis- 
tant the  deformity,  and  it  is  often  convenient  to  consider  the  cases  as 

1st.   Infantile;  i.e.,  infants  in  arms. 

2d.  Walking  cases ;  z".^.,  cases  in  youni^  children  where  the  feet 
have  been  walked  upon  before  the  deformity  has  been  corrected. 

3d.  Resistant  cases ;  i.e.,  those  which  have  resisted  treatment,  or 
where  treatment  has  been  inefficient. 

4th.  Neglected  cases,  those  so  neglected  that  but  little  success- 
ful treatment  has  been  attempted  until  the  feet  have  grown  for 
years  in  a  severely  distorted  position. 

Prognosis. 

In  regard  to  the  prognosis  of  the  deformity,  it  may  be  said  that 
the  distortion  does  not  correct  itself,  and  if  left  uncorrected,  re- 
mains the  most  obstinate  of  malformations. 


Fig.  410. — Infantile  Equino- Varus. 


Fig.  411. — Infantile  Talipes 
Equino-Varus. 


Fig.  412. — Congenital 

Equino-Varus. 


The  deformity  is  one  which  is  essentially  curable ;  in  fact,  it  may 
be  said  that  it  is  always  curable,  provided  care  and  attention  can 
be  given  by  both  surgeon  and  nurse. 

The  amount  of  time  needed  for  treatment  varies  according  to 
the  method  employed.  Formerly  much  time  was  needed  in  the 
treatment  of  inveterate  cases,  but  since  the  introduction  of  tarsal 
resection,  Avhere  this  is  necessary,  it  can  be  accomplished  in  a  few 
months.  The  writers  can  record  a  case  of  severe  and  relapsed 
congenital  club-foot  in  a  boy  of  seven,  which  was  permanently 
cured  in  a  few  weeks  by  astragaloid  osteotomy. 

Ordinarily,  however,  treatment  by  forcible  rectification  and  by 
mechanical  correction,  with  or  without  tenotomy,  requires  a  much 
longer  time.  In  infantile  cases  the  time  required  for  correction  is 
relatively  short,  but  retentiv-e  appliances  are  needed  for  a  longer 
time.  In  fact,  it  may  be  said  in  general,  the  older  the  cases  and 
the  larger  the  foot,  the  more  difficult  the  correction,  but  the  less 
the  danger  of  relapse  after  correction. 


460 


ORTHOPEDIC  SURGERY. 


In  regard  to  the  permanency  of  the  cure  and  the  danger  of  re- 
lapse, it  may  be  said  that  if  perfect  correction  is  attained,  relapse 
is  exceptional,  if  moderate  care  is  used  in  the  employment  for  a 
time  of  retentive  appliance,' 

But  it  must  be  borne  in  mind,  especially  in  the  case  of  young 
children,  not  only  that  the  correction  must  be  complete,  but  ap- 
pliances for  keeping  the  proper  position  of   the  foot  in  walking 


Fig.  413. — Congenital  Talipes 
Equino-Varus. 


Fig.  414. 


Fig.  415. 


Figs.  414,  415. — Slight  Grades  of  Equino-Varus. 


(retentive  or  walking  appliances  to  be  described)  must  be  worn 
until  the  gait  and  attitude  are  perfect.  '  In  club-foot,  half-cures  are 
practically  no  cures. 

Treatment. 

Treatment  of  club-foot  necessarily  varies,  in  a  measure,  accord-^ 
ing  to  the  patient's  age  and  the  duration  and  nature  of  the  deform- 
ity; but  it  may  be  said  in  general  that  the  treatment  should  be 
purely  mechanical,  or  both  operative  and  mechanical. 

The  object  of  treatment  is  the  correction  of  the  distortion  and 
the  retention  of  the  foot  in  a  corrected  position  until  any  return  of 
the  deformity  is  impossible. 

The  treatment  of  club-foot,  therefore,  requires: 

1.  A  rectification  of  the  misplaced  bones,  and  a  lengthening  of 
shortened  and  contracted  tissues. 

2.  A  retention  in  a  normal  position  until  the  abnormal  facet  of 
the  astragalus  and  the  other  tissues  become,  under  the  pressure  of 
new  position,  normal. 

The  first  of  these  can  be  done  by  mechanical  means,  stretching 
or  tearing  the  ligaments  and  tendons  (forcing  the  foot  into  shape),. 

*  Trans,  Amer.  Orthoped.  Society,  Vol.  I.,  Club-foot. 


C/J/ /!-/■< )()'/'. 


461 


or  with  the  help  of  tenotomy  or  incision.  It  may  be  done  ^gradu- 
ally or  quickly. 

The  second  is  purely  a  mechanical  ])robleni,  and  the  retentive 
appliance  should  be  worn  for  a  lonj^er  or  shorter  time,  according 
to  the  size  of  the  distorted  bone  and  the  amount  of  the  distortion. 

The  rational  treatment  of  club-foot  is  of  comparatively  recent 
date. 

Hippocrates  recommended  the  use  of  bandages  and  api)liances  of 
copper,  lead,  or  leather  secured  to  the  skin  by  means  of  resin.  A 
cord  sewn  to  the  bandage  and  wound  around  the  foot  at  the  side 
of  the  small  toe,  pulled  the  foot  outward  when  tightened.  This 
appliance,  it  will  be  seen,  resembles  the  one  recommended  by  Mr. 


Fig.  416. — Congenital  Equino-Varus. 


Fig.  417.— Adult  Club  foot  with  Outer  Edge  of  the  Foot 
Resting  on  the  Ground  in  Walking. 


Barwell,  in  present  use,  Cheselden  recommended  a  starch  bandage, 
which  finds  its  prototype  in  the  modern  plaster  bandage.  But  al- 
though some  attempts  have  always,  in  all  probability,  been  made 
to  correct  club-foot,  there  is  no  reason  to  think  that  in  earlier  times 
any  success  followed  these  attempts.  The  custom  of  distorting  the 
feet  of  Chinese  ladies,  is,  according  to  tradition,  a  relic  of  an  edict 
to  render  the  deformity  of  an  imperial  child  less  noticeable,  by 
making  the  malformation  common — a  confession  of  the  impossi- 
bility of  cure. 

'  This  explanation  of  the  Chinese  custom  is  not,  however,  universally  accepted,  and 
the  origin  is  certainh- obscure.  The  custom  was  present  as  early  as  the  sixth  centur}'  a.d. 
and  the  deformity  .is  referred  to  hy  the  poets  as  indicating  beauty.  This  idea  became  so 
wide-spread  that  although  in  1664  .\.T>.  an  edict  was  published  prohibiting  the  practice  of 
distorting  the  feet,  owing  to  public  opinon  the  edict  was  withdrawn. — Pall  Mall  Gaz., 
1889,  p.  1,074. 


462 


ORTHOPEDIC  SURGERY. 


Even  in  later  times,  up  to  the  beginning  of  this  century,  the 
treatment  of  club-foot  had  fallen  into  such  discredit  that  success 
was  not  regarded  as  possible.  Lord  Byron,  as  is  well  known, 
abandoned  any  attempt  at  correcting  the  deformity  after  being 
treated  for  Several  months  by  Sheldrake,  who,  however,  has  pub- 
lished many  successful  cases. 

At  that  time,  the  treatment  was  purely  mechanical,  but  the  in- 
troduction of  tenotomy  brought  such  apparently  brilliant  results 
that  this  procedure  was  regarded  as  of  itself  a  cure.  So  much  did 
this  theory  prevail,  that  mechanical  treatment  came  to  be  re- 
garded as  of  secondary  importance — a  view  not  held  or  advocated 
by  surgical  authorities  on  the  subject,  but  adopted  so  frequently 
in  practice  that  many  unsuccessful  or  partially  successful  cases 
were  to  be  met.  Recently,  since  the  perfection  of  the  details  of 
antiseptic  and  aseptic    surgery,  more  radical  measures  have  been 


Fig.  418. — Severest  form  of  Club-foot.  Fig.  419. — Severe  Club-foot. 

advocated,  such  as  open  incision,  osteotomy,  and  excision  of  the 
bones  of  the  tarsus  in  the  treatment  of  the  most  inveterate  cases. 

In  addition  to  this,  and  in  a  measure  counter  to  this  tendency, 
the  perfection  of  mechanical  appliances  and  of  correcting  methods 
in  the  last  decade,  have  made  the  treatment  of  many  forms  of  club- 
foot possible  without  such  radical  measures,  or  even  in  many  in- 
stances Avithout  tenotomy. 

It  is  hardly  necessary  to  consider  the  early  methods  of  correc- 
tion of  club-foot,  which,  previous  to  the  time  of  Stromeyer,  were 
entirely  mechanical.  Cures  seem  hardly  to  have  been  attained, 
although  some  successful  cases  are  reported.  In  all  probability 
the  correction  was  incomplete,  and  to-day  would  not  be  consid- 
ered perfect  cures. 

At  the  present  time,  few  procedures  in  surgery  are  as  precise  in 
their  indications  and  as  certain  in  their  results  as  the  methods  for 
the  correcting  of  club-foot. 

The  correction  of  club-foot  should  be  divided  into  two  steps, 
whether  the  treatment  is  mechanical  or  operative. 


CJMr.-l'OOT. 


4^^3 


1st.  Correction  o{  the  varus  deformity. 

2d.   Correction  of  the  equinus  deformity. 

In  other  words,  the  front  of  the  foot  should  be  twisted  out  and 
afterward  be  raised.  This  will  be  found  of  practical  importance, 
as  the  foot  is  more  easily  twisted  before  than  after  the  equinus 
deformity  is  overcome.  In  addition  to  this,  as  there  is  invariably 
some  alteration  in  the  facet  of  the  astragalus,  some  mechanical 
form  of  retention  of  the  corrected  foot  is  necessary,  until  the  bone 
adapts  itself  or  is  shaped  to  the  normal  position  and  until  the  mus- 
cles of  the  foot  and  leg,  altered   by  the  distortion,  recover  their 


Tfjre^jjy 


Fig.  420. — Severest  form  of  Club-foot. 

normal  tonicity.  In  short,  treatment  involves  methods  of  correc- 
tion and  of  retention  of  the  corrected  position. 

The  methods  of  correction  are  either  mechanical,  or  a  combina- 
tion of  both  mechanical  and  operative  means. 

The  operative  procedures  which  are  to  be  considered  in  treating 
club  foot  are: 

Tenotomy. 

Division  of  the  ligaments. 

Incision. 

Forcible  correction  and  excision. 

Mechanical  Correction. — The  simplest  method  of  correction  is  by 
the  use  of  the  hands,  and  in  the  case  of  a  new-born  infant  with 
club-feet,  the  mother  may  be  directed  to  manipulate  the  foot,  and 


464  *  ORTHOPEDIC  SURGERY. 

having  rectified  the  deformity  by  gentle  force  several  times  daily, 
to  hold  it  as  straight  as  possible  for  a  minute  or  two  each  time. 
The  writers  can  record  the  result  of  a  case  of  congenital  deformity 
of  one  foot,  in  a  child  under  a  year  old,  where  the  treatment  was 
thoroughly  and  continuously  carried  out  by  a  nurse  and  mother 
alternately  for  three  months.  At  the  age  of  five,  the  child  pre- 
sented an  equino-varus  foot  of  moderate  type  as  to  deformity,  but 
severe  as  to  resistance.  In  walking  the  weight  fell  chiefly  on  the 
outer  side  of  the  sole;  the  foot  could  be  nearly  brought  into  a 
normal  position  by  the  use  of  moderate  force,  but  the  deformity 
could  not  be  over-corrected.  A  tenotomy  of  the  tendo  Achillis 
was  done  a  year  later,  and  under  free  manipulation  possible  from 
anaesthesia,  well-marked  distortion  of  the  neck  and  articular  facet 
of  the  astragalus  was  found.  It  is  a  treatment  which  requires  so 
much  persistence,  that  it  is  impossible  that  it  can  be  thoroughly  or 
definitely  curative. 

Another  ready  method  in  correcting  club-foot,  is  by  repeated 
fixation  in  a  plaster-of-Paris  bandage,  the  foot  being  held  as  nearly 
in  a  corrected  position  as  possible  at  each  application  of  the  band- 
age until  the  bandage  hardens.  The  bandage  should  reach  above 
the  knee,  where  the  lim.b  should  be  slightly  bent  to  prevent  the 
plaster  bandage  (which  should  be  renewed  every  two  or  three 
weeks)  from  rolling  around  the  limb,  and  to  prevent  the  child  from 
kicking  it  off.  This  method  is  chiefly  applicable  to  young  children 
or  infants  and  can  be  made  efificacious. 

In  the  case  of  small  children  with  plump  legs,  and  in  resistant 
cases,  it  will,  however,  be  found  difficult  to  prevent  the  heel  from 
being  drawn  away  from  the  bandage,  and  stretching  of  the  tendo 
AchiUis  will  by  this  method  be  fedious. 

This  method  has  the  disadvantage  of  being  tedious,  but  it  has 
many  advantages  in  being  a  practical  method,  readily  applied,  and 
not  leaving  details  of  application  to  the  patient's  parents.  It  is 
evident  that  correction  in  this  way,  if  persistently  applied,  is  possi- 
ble. If  the  Chinese '  can  produce  an  extreme  deformity  by  band- 
aging the  children's  feet,  the  same  method  could  be  employed  for 
the  correction  of  deformity,  but  this  can  only  be  done  at  the  ex- 
pense of  considerable  time  and  patience. 

Mechanical  (without  tenotomy)  correction  by  means  of  ap- 
pliances  is  much  less  clumsy  than  the  method  of  correcting  by 


^  Descriptions  of  the  method  of  the  Chinese  have  been  given  from  time  to  time  by 
travellers.  It  would  appear  to  consist  of  tight  bandaging  of  the  foot.  The  bandages  are 
soaked  in  a  preparation  of  benzoin  and  are  wound  successively  around  the  foot  as  tightly  as 
possible.  The  toes  drop  off  occasionally  from  gangrene.  There  is  great  pain  at  first,  but 
'subsequently  it  diminishes.     The  process  is  continued  for  a  year  or  more. 


CIAin-l'OOT. 


465 


repeated  plaster  bandages.  The  sim[>le  use  of  bandages  forcing 
the  foot  to  the  shape  with  light  appliances  of  tin  set  at  various 
angles,  or  of  steel  shoes  which  can  be  placed  in  proper  position, 
has  been  successfully  employed.  The  method,  however,  requires 
much  persistence  on  the  i)art  of  the  surgeon,  if  a  perfect  cure  is 
expected. 

The  most  efficient  and  thorough  application  of  this  method  of 
treatment  is  exemplified  by  the  appliance  devised  and  used  by  Dr. 
C.  F.  Taylor,  of  New  York,  which  is  illustrated  in  the  accompany- 
ing cuts  (Figs.  421,  422,  423). 


Fig.  422. — Taylor  Shoe  in  Process  of  Adjustment. 
The  sole  plate  applied  and  the  foot  strapped  to  the 
sole  plate. 


Fig.  421. — Taylor  Varus  Shoe  for  theLeft  Foot.  Fig.  423. — The  Upright  Brought  into  Place  and 

acting  as  a  Lever  turning  the  Foot  to  the  Outer  Side. 


The  appliance  consists  of  a  flat  steel  sole  plate,  which  follows 
the  outline  of  the  lower  surface  of  the  foot,  reaching  forward  to 
the  balls  of  the  toes;  at  right  angles  to  this  rises  an  inner  border, 
from  which  a  shaft  extends  up  the  leg  at  right  angles  to  the  sole 
plate,  the  apparatus  being  jointed  at  the  ankle.  The  foot  is  re- 
tained to  the  sole  plate  by  straps  of  webbing  buckling  over  it. 
The  apparatus  acts,  by  the  leverage  of  the  upright,  to  throw  the 
foot  into  a  correct  position.  The  sole  plate  is  applied  to  the  de- 
formed foot  and  the  upright  is  brought  into  position,  as  shoAvn  in 
the  figure,  forcing  the  foot  into  place.  The  shoe  is  light  and  can 
be  worn  inside  the  boot  without  interfering  with  locomotion. 

The  sole  is  well  retained  on  the  sole  plate  by  means  of  straps, 
and  the  heel,  in  resistant  cases,  can  be  kept  well  down  to  the  plate 
30 


466  ORTHOPEDIC  SURGERY. 

by  the  application  of  adhesive  plaster  to  the  leg;  the  free  ends  of 
these  plasters  are  sewn  to  webbing  and  are  secured  by  buckles  on 
the  sole  plate.' 

The  appliance  can  be  made  by  any  blacksmith  or  instrument 
maker,  who  can  be  furnished  by  the  surgeon  with  a  cardboard 
pattern  of  the  sole  plate ;  but  it  is  essential  that  the  appliance 
should  be  carefully  fitted,  the  straps  adjusted  and  altered  from 
time  to  time,  demanding  much  care  and  skill  on  the  part  of  the 
surgeon,  which  cannot  be  safely  delegated  to  the  instrument  maker. 

After  correcting,  the  patient  can  walk  with  the  appliance,  which 
can  be  worn  within  a  shoe,  and  in  severe  cases  can  be  carried 
above  the  knee  and  around  the  waist. 

Severe  cases  of  congenital  club-foot  have  been  corrected  and 
cured  permanently  by  Dr.  Taylor  in  this  way.  The  method,  how- 
ever, requires  skill,  time,  and  persistency."" 

Splints  for  the  treatment  by  bandaging  can  be  made  of  tin, 
pasteboard,  and  stiffened  felt,  and  cases  are  sometimes  met  which 
have  been  exclusively  treated  by  means  of  these  appliances. 

The  accompanying  illustration  (Fig.  424)  represents  a  case  of  dou- 
ble congenital  club-foot  which  had  been  nearly  corrected  by  several 
years'  treatment  under  the  care  of  an  advertising  physician,  whose 
treatment  consisted  in  bandaging  the  foot  to  light  steel  splints 
which  could  be  worn  inside  the  shoe.  The  varus  deformity  was  cor- 
rected, but  a  slight  amount  of  equinus  deformity  remained.  Tenot- 
omy and  subsequently  mechanical  correction  was  needed  to  bring 
the  foot  into  a  proper  position,  in  order  that  walking  without  some 
inversion  of  the  foot  was  possible.  The  previous  treatment  in  the 
case  was  sufficiently  successful  to  illustrate  what  could  be  accom- 
plished by  persistent  and  thorough  bandaging,  in  a  case  of  average 
severity.  The  foot,  if  covered  by  a  new  shoe,  presented  little  or  no 
deformity,  but  in  walking,  the  characteristic  roll  and  twist  of  the 
feet  were  noticed,  and  increased  as  the  child  grew  older.  After 
tenotomy  and  thorough  correction  of  the  equinus,  the  foot  re- 
mained cured  without  relapse. 

An  excellent  appliance  for  the  correction  of  infantile  club-foot 
has  been  devised  by  Beely.  A  slight  modification  of  this  will  be 
seen  in  the  accompanying  pictures.  It  is  light,  not  expensive,  and 
can  be  used  very  readily  by  the  mother  or  nurse.  The  method 
has  been  used  by  the  writers  chiefly  in  infantile  cases,  but  it  has 
also  been  employed  in  older  children  (Figs.  425,  426). 

Two  steel  strips,  of  a  strength  varying  according  to  the  case, 

'  The  illustration  shows  a  form  of  fixed  fastening  which  will  be  found  of  convenience 
in  place  of  buckles,  less  room  being  needed  in  the  shoe  (Fig.  424). 
^  Trans.  Am.  Orthop.  Society,  vol.  i. 


C7J/ />•-/■(>()'/: 


467 


are  cut  of  proper  lenj^tli  and  conm-ctcl  hy  an  ordinary  joint  allow- 
ing free  motion.  The  upper  end  of  W  is  cf^nnected  with  a  bent 
strip  of  tempered  steel  long  enough  to  encircle  half  the  patient's 
pelvis,  a  leather  strap  F  completing  the  circle.  The  lower  end  of 
A  is  bent  so  as  to  pass  under  the  foot,  and  has  two  l)uckles,  0  11, 
to  receive  adhesive  plasters  on  the  jjatient's  leg,  used  for  the 
purpose  of  keeping  the  heel  well  in  the  appliance.  A  cross  steel 
strip  D,  padded,  passes  in  front  of  the  leg  above  the  ankle,  and 
with  a  strap  which  goes  behind,  lujlds  the  leg  from  slipping  for- 
ward or  backward.  A  steel  rod  C  projects  to  the  outer  side  (A  the 
foot.  It  should  be  strong  enough  to  stand  ordinary  strain,  but 
soft-tempered  and  capable  of  being  bent  by  a  wrench;  it  furnishes 


Fig.  424. — Equinus  not  Completely 
Corrected. 


Fig.  425.  Fig.  426. 

Figs.  425,  426. — Modified  Beely  Correcting  Appliance. 


the  point  from  which  a  pull  upon  the  deformity  can  be  made.  A 
small  padded  plate  I  protects  the  pressure  which  falls  upon  the 
side  of  the  astragalus  and  os  calcis.  The  limb  can  in  this  way  be 
firmly  held  in  the  appliance.  The  child  cannot  kick  it  off,  and  there 
is  no  pressure  on  the  dorsum  of  the  foot  to  cause  pain  or  sloughs. 

The  pull  upon  the  foot  is  effected  by  means  of  a  strip  or  strips 
of  adhesive  plaster  wound  about  the  foot  at  the  level  of  the  ball  of 
the  toes,  the  free  end  being  long  enough  to  reach  the  end  of  ^the 
arm  C,  which  can,  if  desired,  be  furnished  with  a  buckle,  into  which 
the  webbing  sewn  on  to  the  end  of  the  plaster  can  be  buckled,  or 
the  plaster  alone  may  be  wound  over  the  end  of  the  steel  rod.  If 
it  is  desired  to  furnish  elastic  tension,  elastic  webbing  can  be  used ; 
but  a  continued  pull,  increased  by  tightening  as  the  deformity  is 
■corrected,  will  be  found  satisfactory. 


468 


OR  THOPEDIC  S  UR  GER  Y. 


To  protect  the  inside  of  the  great  toe  from  being  cut  by  the 
pulling  adhesive  plaster,  it  can  be  covered  by  a  strip  of  smooth 
leather;  and  to  prevent  the  adhesive  plaster  from  slipping  back,  a 
second  strip  of  plaster  can  be  wound  close  to  the  first  on  the  prox- 
imal side  of  the  foot. 

The  side  arm  C  is  to  be  bent  as  the  foot  is  corrected,  the  end 
being  placed  at  the  point  from  which  it  is  desired  that  the  pull 
should  come.  If  desired,  the  arm  C  can  be  connected  with  the 
upright  A  by  means  of  a  double  screw  joint,  so  that  motion  and 
direction  of  the  arm  can  be  regulated  by  key.  This,  however,  in- 
creases the  expense  of  the  appliance  without  adding  to  the  efifi- 
ciency.     Thorough  abduction  of  the  foot  should  precede  elevation 

or  correction  of  the  rotation. 
Instead  of  the  plasters  pulling 
upon  the  foot,  bandages  can  be 
used,  bandaging  the  foot  to  the 
arm  C.  If  holes  are  cut  in  the 
stocking  and  shoe  so  that  the 
free  ends  of  an  adhesive  plas- 
ter may  pass  through,  the  ap- 
pliance can  be  used  with  the 
patient  wearing  shoes  and 
stockings. 

The  ef^cacy  of  the  appli- 
ance depends  chiefly  on  the 
handiness  used  in  applying  it. 
No  especial  skill  is  required 
to  tighten  the  straps;  and  this 
can  easily  be  left  to  the  nurse. 

Fig.  427. — Elastic  Traction  Appliance  with  Ankle  Strap.    •vYJf-Vi     the      dirCCtion      that      the 

side  straps  should  be  kept  as  tight  as  possible.  The  adhesive 
plaster  should  be  changed  every  three  or  four  days,  and  this  can 
be  done  by  the  nurse  without  difificulty.  Some  skill  is  required 
in  designing  and  fitting  the  appliance,  it  being  essential  that  the 
foot  and  leg  are  well  held  in  it,  'and  that  the  steel  is  strong 
enough. 

Correctio7i  by  Means  of  Straps  and  by  a?i  Elastic  Force. — -The  use 
of  9.n  elastic  force  to  overcome  contraction  can  be  employed  in  the 
correction  of  club-foot  as  of  other  deformities.  It  has  been  recom- 
mended by  Davis  and  Barwell  and  Sayre. 

Various  appliances  have  been  devised  to  employ  elastic  correc- 
tion, and  on  the  theory  that  the  elastic  force  supplemented  the 
weaker  muscles,  the  method  was  regarded  "as  physiological;  but 
though  the  method  will  be  found   of  use  in  some  of  the  lighter 


CLUI!-I-()()'J\ 


469 


cases,  yet  it  has  not  seemed   to  the  writers  supcrif>r  to  other  ways 
of  mechanical  correction. 

The  illustration  (Figs.  427,  430J  rcjjrcscnts  an  ,-ip])lia)icc  for  elas- 
tic correction  which  has  been  recommended  and  is  in  use-.  In 
practice,  the  appliance  will  be  found  deficient  in  a  tendency  to  turn 
about  the  leg,  and  this  defect  can  in  a  measure  be  overcome  by 
ingenuity  on  the  part  of  the  surgeon.  To  obviate  this  and  to  avoid 
the  necessity  of  an  appliance,  the  following  expedient  will  be 
found  of  service,  recommended  by  Barwell  and  Sayre.  A  fixed 
point  is  secured  to  the  side  of  the  leg  by  adhesive  plaster  and  band- 
ages and  another  point  at  the  side  of  the  foot,  and  these  two  points 
are  connected  by  elastic  tubing.  The  writers  have  obtained  ex- 
cellent results  by  these  means,  but   the  method  is  often  a  tedious 


Fig.  428. — Plate  Applied  to  Leg 
with  Adhesive  Plaster. 


Fig.  429. — Rubber  Tubes 
and  Chain  connecting  Foot 
with  Plates. 


2^       D- 

Fig.  430. — Elastic  Traction  Shoe.  i>, 
steel  upright;  C,  leg  band;  Z?,  joint  at 
ankle;  E^  elastic  rubber  tubes;  G,  side 
hook;  //,  dorsal  hook. 

one,  unless  aided  by  tenotomy.  In  rhe  severest  cases,  it  is  not 
applicable  and  the  plaster  at  times  causes  troublesome  irritation 
of  the  skin. 

De  Forrest  Willard  has  employed  the  same  method  of  treat- 
ment without  the  use  of  plaster;  lacing  bands  around  the  foot  and 
leg  {b  and  a)^  and  connecting  them  with  an  elastic  strap. 

In  place  of  elastic  tubing,  elastic  webbing  can  be  employed,  and 
the  writers  have  found  the  non-elastic  webbing,  secured  to  a  buckle 
and  frequently  tightened,  fully  as  efficient  as  the  elastic. 

Thomas,  of  Liverpool,  and  Taylor,  of  New  York,  have  both  dem- 
onstrated that,  if  the  foot  can  be  prevented  from  twisting  or  rolling 
by  any  appliance,  the  weight  in  walking  in  a  child  of  any  size, 
if  thrown  fairly  upon  the  foot,  will  act  in  correcting  the  equinus 
deformity.  To  do  this  effectually,  the  knee  should  be  kept  from 
bending;    this  can   revadily  be  done  by  means  of  a  simple  Thomas 


470 


ORTHOPEDIC  SURGERY. 


caliper  splint  for  knee-joint  disease,  and  any  appliance  fixing  the 
thigh  high  up  and  not  jointed  at  the  knee.  This  method  will  not 
be  efficient  in  cases  of  extreme  equinus,  but  it  will  be  found  a  help 
in  cases  with  moderate  contraction. 

In  the  mechanical  correction  of  more  resistant  cases  considerable 
force  is  required,  and  the  most  common  application  is  by  means  of 
screw  power.  This  is  employed  chiefly  after  tenotomy ;  but  Shaffer, 
of  New  York,  has  advocated  the  employment  of  mechanical  daily 


Fig.  431. — Willard's  Elastic  Traction. 


Fig.  432. — Elastic  Traction  Appliance. 


Fig.  433. — Beely's  Appliance  with  Elastic  Traction. 


stretching  by  means  of  the  use  of  carefully  devised  appliances.  As 
much  force  is  employed  as  can  be  borne  by  the  patient  for  a  few 
moments,  and  this  is  repeated  frequently.  The  intermittent  applica- 
tion of  great  force  has  been  found  sufficient  by  Shaffer  to  correct, 
in  time,  severe  deformities. 

He  employs  two  appliances,  one  for  correction  of  the  inversion  of 
the  foot,  and  the  other  for  correcting  the  equinus  deformity.  In 
the  latter,  Dr.  Shaffer  considers  the  traction  of  the  fore  part  of  the 
foot  as  of  importance  in  stretching  the  plantar  fascia,  and  his  ap- 
pliance is  devised  with  a  view  to  accomplishing  this.     The  shoe  for 


CLUn-FOOT. 


471 


the  correction  of  the  equinus  element  in  talipes  is  seen  in  the  fi^^ure. 
The  shoe  is  applied  to  the  foot  in  its  deformed  position,  and  a  firm 


Fig.  434. — Extension  Shoe. 


Fig.  435. — Shaffer's  Appliance  for  Plantar 
Traction  in  Club-foot, 


Fig.  437- -Shaffer's  Correcting  Appliance.  Fig.  43S.-Shaffer's  Correcting  Appliance. 

retentive  strap  is  carried  over  the  head  of  the  astragalus,  while  a 
second  strap  runs  from  behind  the  heel  to  the  front  of  the  shoe. 


472 


ORTHOPEDIC  SURGERY. 


The  joint  at  the  ankle  is  then  turned  until  the  foot  is  decidedly 
more  flexed.  The  rack  and  pinion  key  is  used  under  the  foot, 
which  pushes  the  foot-piece  forward,  and  draws  the  heel  downward. 
The  action  of  the  lateral  traction  shoe,  which  combines  extension 
and  eversion^  of  the  anterior  part  of  the  foot,  is  best  explained  by 
the  diagrams.  The  accompanying  figures  (Figs.  437,  438)  show 
a  diagram  of  the  apparatus  as  it  would  be 
applied  to  an  equino-varus  of  the  left  foot. 
The  centre  of  motion  is  at  A  (directly  over 
the  external  malleolus).     The  anterior  part 


Fig.  440.  Fig.  441. 

Shaffer's  Appliance  for  the  Eversion  of  the  Foot  in  Club-foot. 


of  the  foot  rests  upon  B,  held  in  place  laterally  by  C.  The  heel  is 
held  by  an  astragalus  retention  strap  (Figs,  439,  440,  441). 

Shaffer  has  also  employed  an  appliance  for  pushing  the  foot 
outward,  as  is  seen  in  the  accompanying  figures. 

Combined,  Operation  and  Mechanical  Method  of  Treatment. — A 
combination  of  operative  and  mechanical  methods  of  treatment,  is 
at  present  the  most   common    mode  of    treating   club-foot.     The 


CLU/l-J'VOT. 


473 


operative  interference  most    frecjuently  resorted    to,  is    tenotomy 
and  subcutaneous  division  of  the  fasciae  or  ligaments. 

Tcno/o!ny.—Y)Q.\]}cz\\,  j^aiided  by  accidental  section  and  ruptures 
of  the  tendon,  was  the  first  to  define  the  indications  for  a  scientific 
tenotomy,  and  thus  made  an  important  advance  in  the  treatment 
of  club-foot.  Stromeyer,  liouvier,  (iuerin,  Little,  and  Adams  have 
made  the  operation  popular  and  within  the  reach  of  every  surgeon. 

In  the  section  of  the  tendons,  the  incision  can  be  made  either  from 
the  skin  toward  the  tendon,  or  sometimes  one  may  pass  the  tenotome 
underneath  the  tendon  and  cut  toward  the  skin.  Bouvier  calls 
the  two  methods  of  procedure  sub-  and  supra-tendinous  section, 
and  according  to  this  surgeon  a  choice  is  a  matter  of  indifference, 
but  the  sub-tendinous  method  is  sometimes  to  be  preferred  as  the 
most  simple  in  its  execution  and  one  per- 
mitting complete  section  of  the  tendon 
without  risking  the  skin.  The  supra- 
tendinous  method  is  to  be  preferred 
where  the  tendons  are  not  very  salient, 
as  in  young  children,  or  in  tendons  close 
to  the  bone  or  in  the  neighborhood  of 
vessels  and  important  nerves.  The  ten- 
don which  is  most  frequently  divided  in 
equino-varus  is  the  tendo  Achillis. 

Section  of  the  Tendo  Achillis. — The  pa- 
tient should  lie  upon  his  face  and  an  assis- 
tant should  hold  the  foot;  the  surgeon, 
having  made  a  longitudinal  fold  of  the  skin,  enters  the  knife  parallel 
to  the  border  of  the  tendon,  passing  the  tenotome  flatwise  between 
the  tendon  and  the  skin.  This  having  been  done,  the  blade  of  the 
knife  is  turned  toward  the  posterior  surface  of  the  tendon  and  the 
assistant  raises  the  end  of  the  foot  so  as  to  stretch  the  tendo 
Achillis  slightly.  The  left  index  finger  presses  on  the  skin  over 
the  back  of  the  tenotome,  and  in  this  way  the  sensation  of  the  cut- 
ting of  the  tendon  can  be  felt. 

The  only  precaution  necessary  is  to  be  assured  that  the  tendon  is 
completely  divided.  When  the  operation  is  done,  the  extravasated 
blood  is  squeezed  out  of  the  opening  and  a  small  amount  of  aseptic 
cotton  is  placed  over  the  wound.  The  operation  should  be  done 
antiseptically  and  an  aseptic  dressing  applied. 

Section  of  the  Tibialis  Posticus. — Section  of  the  tibialis  posticus 
is  done  in  the  following  way:  If  the  muscle  is  divided  in  the  leg, 
the  foot  is  placed  on  its  external  border.  The  surgeon  divides  the 
skin  by  means  of  a  pointed  tenotome  two  centimetres  above  the 
tip  of  the  internal  malleolus  and   on  a  vertical  line  situated  half- 


FiG.  442. — Position  of  Hands  in  Holding 
Foot  lor  Tenotomy. 


474  ORTHOPEDIC  SURGERY. 

way  between  the  posterior  border  of  the  malleolus  and  the  corre- 
sponding border  of  the  tendo  Achillis.  The  tenotome  should  be 
directed  perpendicularly  downward  to  the  depth  of  one,  ©r  one  and 
one-half  centimetres.  Then  the  handle  of  the  instrument  should 
be  turned  -so  as  to  describe  the  arc  of  a  circle  and  the  tendon 
divided  vertically  inward.  This  having  been  done,  the  tenotome 
is  withdrawn  and  a  blunt-pointed  one  inserted.  This  should  be 
directed  so  as  to  pass  behind  and  under  the  tendon  of  the  tibialis 
posticus,  and  then  it  is  sufficient  to  turn  the  cutting  edge  forward 
and  to  move  the  instrument  gently  forward  and  back,  while  the  as- 
sistant at  the  same  time  turns  the  foot  forcibly  in  the  direction  of 
abduction. 

It  is  essential,  in  order  to  avoid  the  important  parts,  to  adhere 
strictly  to  the  rules  laid  down.  If  the  incision  is  made  too  near 
the  malleolus,  the  internal  saphenous  vein  and  nerve  may  be  cut. 
If  the  incision  is  made  too  near  the  tendo  Achillis,  there  is  danger 
of  dividing  the  tendon  of  the  long  flexors  of  the  toes  and  the 
posterior  tibial  artery  and  nerve.  Bonnet  thinks  he  has  wounded 
this  artery  more  than  once,  but  without  serious  injury.  To  avoid 
this  possibility,  Velpeau  advised  cutting  the  tendon  of  the  tibialis 
posticus  on  the  foot  from  a  line  extended  from  the  top  of  the  in- 
ternal malleolus  to  the  scaphoid,  but  this  is  not  easily  done  in  in- 
fants. 

The  writers  would  record  the  puncture  of  the  posterior  tibial 
artery  at  the  point  of  a  tenotome  and  the  formation  of  an  aneur- 
ism which  required  ligation,  but  caused  no  subsequent  annoyance. 
The  Tendon  of  the  Tibialis  Ajiticus. — The  tendon  of  the  tibialis 
anticus  is  divided  more  easily.  For  this  purpose  it  is  sufficient  to 
be  guided  by  the  prominence  of  the  tendon  put  on  a  stretch  by 
abducting  the  foot.  To  avoid  the  wounding  of  fhe  deep  parts,  it  is 
better  to  enter  the  tenotome  under  the  tendon.  It  is  often  neces- 
sary to  divide  also  the  plantar  fascia.  Some  writers  advise  dividing 
the  plantar  fascia  before  the  tendo  Achillis,  as  the  latter  acts  as  a 
means  of  support  for  stretching  the  foot  when  the  plantar  fascia  is 
divided. 

Division  of  tJie  Plantm-  Fascia. — The  plantar  fascia  is  divided  in 
the  same  way  that  the  tendons  are  incised.  The  most  prominent 
portion  of  the  fascia  is  the  point  of  election  for  subcutaneous  in- 
cision. The  fascia,  it  must  be  borne  in  mind,  is  not  a  narrow  band, 
but  a  broad  ligament  needing  a  long  subcutaneous  incision.  The 
tenotome  should  be  inserted  on  the  inner  side  of  the  sole  nearly 
half-way  between  the  os  calcis  and  the  ball  of  the  foot,  but  nearer 
to  the  OS  calcis.  The  tenotome  is  to  be  pushed  subcutaneously 
nearly  across   the   sole,  the   edge   of  the  knife  turned  toward  the 


CLUn-J'OOT. 


475 


fasciae,  and  the  knife  drawn  across  the  fascia,  which  will  be  felt  to 
give  way  as  it  is  divided;  an  assistant  should  make  ui)ward  pressure 
upon  the  ball  of  the  foot,  in  ordc:r  to  put  the  fascia  on  the  stretch. 
As  the  artery  lies  deei)ly,  there  is  no  danger  of  injuring  it,  if  ordi- 
nary care  is  used. 

The  tenotomes  used  should  be  strong  at  the  neck,  and  the  cut- 
ting edge  should  not  be  too  long,  as  the  skin  is  necessarily  divided 
if  too  long;  a  cutting  edge  is  used  in  operating  on  infantile  cases, 
which  require  a  much  smaller  instrument.  Tenotomes  should  be 
of  two  sorts,  one  with  a  short,  pointed  end,  for  thrusting  into  the 
skin  and  under  the  tendon,  and  a  blunt-pointed  one  which  can 
follow  where  there  is  danger  of  wounding  an  artery  by  a  sharp 
point.  Curved  tenotomes  are  sometimes  of  use,  especially  for  di- 
vision of  the  scapho-astragaloid  ligament. 

Tenotomes  as  furnished  by  instrument  makers  are  ordinarily 
much  too  large,  and  though  service- 
able in  myotomy,  are  better  for  ten- 
otomy in  children  if  smaller  than  is  ||! 
indicated  in  the  accompanying  cut. 
The  neck  should  be  strong,  as  the 
breaking  of  the  tenotome  in  the 
wound  (an  accident  which  once  hap- 
pened in  the  experience  of  the 
writers)  gives  annoyance. 

TJie  Repair  of  Divided  Tendons. — 
The  reparative    process  of    divided 

,1  11  J  u  •       ^         Fig.  44T. — Different  forms  of  Tenotomes. 

tendons    has    been    made   a  subject 

of  numerous  investigations,  since  Hunter's  original  experiments  in 
1767,  and  has  been  recently  studied  with  much  care  by  Mr.  Adams. 
When  a  tendon  is  divided,  the  cut  ends  are  separated  to  a  vari- 
able extent,  depending  upon  the  retraction  of  the  muscle  to  which 
it  belongs ;  upon  the  position  in  which  the  limb  is  placed ;  and  upon 
the  surrounding  attachments  of  the  tendon.  Extending  beneath 
the  ends  of  the  tendon  is  its  tubular  sheath  of  connective  tissue, 
and  it  is  this  which  chiefly  furnishes  the  reparative  material. 

The  sheath  becomes  vascular  and  succulent,  and  after  the  ab- 
sorption of  any  blood  that  may  have  been  effused  within  it,  the  in- 
terval between  the  divided  ends  of  the  tendons  becomes  filled  with 
lymph,  which  gradually  becomes  fibrillated  and  forms  a  firm  bond 
of  union  between  them. 

The  new  material  so  closely  resembles  the  old  tendon  and  is  so 
intimately  blended  with  it,  that  for  a  time  it  would  be  difficult  to 
distinguish  them,  except  for  a  certain  translucency  which  is  pos- 
sessed by  the  former,  and  is  not   natural  to  the  latter.     By  this 


y^ye  ORTHOPEDIC  SURGERY. 

means  the  divided  tendon  is  increased  in  length  to  the  extent  of 
the  interval  by  which  its  ends  are  separated,  and  elongation  will 
vary  according  to  the  amount  of  separation. 

If  after  the  operation,  treatment  is  carried  out  with  ordinary 
care  and  skill  on  a  healthy  subject,  a  perfect,  useful  muscle  of  the 
normal  length  is  obtained. 

Adhesions  may,  and  doubtless  often  do,  form  between  the  di- 
vided tendons  and  the  surrounding  structure,  but  in  ordinary  cases 
they  are  not  of  consequence,  for  they  give  way  to  the  manipulation 
of  use  of  the  foot,  and  do  not  interfere  with  the  function  of  the 
muscle. 

Much  undeserved  opprobrium  for  a  time  fell  upon  the  procedure 
of  tenotomy.  In  half-cured  and  relapsed  cases,  atrophy  of  func- 
tional disability  of  the  muscles  will  be  found;  but  there  is  no  evi- 
dence to  demonstrate  that  tenotomy,  when  properly  performed, 
exerts  an  unfavorable  influence  upon  the  muscle. 

Division  of  the  Ligaments. — Division  of  the  ligaments  has  been 
regarded  as  useful  by  many  operators.  Parker  and  Shattuck  have 
lately  called  especial  attention  to  the  importance  of  this  use  of  the 
tenotome.' 

For  division  of  the  astragalo-scaphoid  ligament,  the  skin  and 
soft  tissues  should  be  punctured  down  to  the  bone  by  the  insertion 
of  the  tenotome.  A  curved  blunt-pointed  tenotome  should  then 
be  inserted  in  front  of  the  internal  malleolus  and  pushed  directly 
to  the  underlying  bone,  and  swept  subcutaneously  around  the 
bone,  keeping  close  to  it.  The  knife  should  be  kept  between  the 
skin  and  ligaments,  and  the  latter  dividend  by  a  sawing  motion  of 
the  tenotome.  This  division,  if  satisfactorily  and  thoroughly  made, 
may  serve  in  certain  cases  as  a  substitute  for  the  division  of  the 
tibialis  tendons. 

The  calcaneo-cuboid  ligament  should  also  be  divided  in  severe 
cases.  The  tenotome  should  be  inserted  a  short  distance  behind 
the  head  of  the  fifth  metatarsal  bone,  near  the  articulation  of  the 
OS  calcis  and  cuboid,  which  can  be'  felt  on  palpation.  The  sharp- 
pointed  tenotome  should  be  inserted  to  the  bone,  and  then  by 
careful  motion  the  whole  ligament  should  be  divided. 

The  age  at  which  patients  should  be  operated  on  is  a  matter  of 
discussion.  Some  writers  claim  that  operation  should  not  be  done 
before  the  end  of  the  first  year,  and  others  claim  that  it  is  advisable 
to  interfere  as  soon  as  possible.  Stromeyer  has  operated  on  a 
patient  twenty-four  hours  old. 

The  reputed  growth  of  a   child's  foot  is  indicated  by  the  mea- 

^  London  Path.  Soc. ,  British  Med.  Journal,  1886,  vol.  ii.,  p.  10. 


CLun-/'()()T.  477 

surements  of  Quctclct  and  Langer.  A  cljild  3  months  old  has  a 
foot  75  to  85  millimetres  long,  at  6  nionllis  loi  millimetres,  at  one 
year  107  millimetres,  at  15  nioiillis  112  millimetres,  at  18  months 
116  millimetres,  at  21  nionlhs  119  millimetres  and  at  20  months 
122  millimetres. 

That  is  to  say,  the  foot  increases  with  less  rapidity  the  older  the 
child  grows,  and  if  the  foot  is  left  to  itself,  the  deformity  greatly 
increases  in  the  first  months  of  life.  It  is,  therefore,  rational  to 
claim  that  the  sooner  the  foot  is  corrected  the  better,  provided  the 
patient's  general  condition  will  endure  the  undertaking,  and  that 
treatment  is  not  liable  to  be  interrupted  by  intercurrent  infantile 
disorders;  practically,  treatment  should  be  undertaken' as  soon  as 
an  infant  is  nursing  well  and  is  in  reasonable  health. 

Mechanical  Appliances  after  Tenotomy. — After  tenotomy,  correc- 
tion can  be  made  either  immediately  or  gradually.  The  latter 
method  is  the  one  recommended  by  many  English  writers,  who 
advise  delay  in  rectification  of  the  foot  after  tenotomy  to  avoid 
the  supposed  danger  of  non-union  of 
tendons. 

Although  this  delay  of  rectification 
is  recommended  by  excellent  author- 
ity, the  writers  do  not  hesitate  here  to 
consider  it  as  unessential,  and  entail- 

,  .  1'  u;.  444.  Fig.  445. 

mg  upon  the  patient  an  unnecessary 

amount  of  delay  and  inconvenience.  Sufficient  clinical  evidence  has 
been  collected  to  warrant  the  assertion  that  in  congenital  club-foot, 
the  danger  of  non-union  of  the  tendo  Achillis  following  immediate 
rectification  is  theoretical  rather  than  practical,  and  that  by  imme- 
diate rectification  and  over-correction  of  the  club.foot,  the  patient 
is  saved  much  time.  This  view  is  sustained  by  the  opinion  of 
many  excellent  authorities  on  the  subject. 

As  will  be  discussed  in  detail  later,  the  writers  prefer  immediate 
correction,  or  in  fact  over-correction,  after  tenotomy  as  being  the 
most  thorough  and  speedy,  where  operative  interference  is  needed. 
The  simplest  and  best  retention  apparatus  for  immediate  use  is  a 
simple  light  plaster-of-Paris  bandage  applied  immediately  after 
operation. 

Cases  of  ordinary  severity  can  be  treated  in  this  way  The  oper- 
ation is  not  a  difficult  one,  and  the  correction  can  be  made  by 
manual  force  and  the  over-corrected  foot  retained  by  means  of  an 
inexpensive  and  ready  appliance  furnished  by  a  plaster  bandage. 
After  removal  of  the  plaster  bandage,  a  walking  appliance  worn 
for  a  while  prevents  relapse. 

Figs.  444  and  445  represent   casts  of  a  foot  before  and  after  such 


478 


OR  THOPEDIC  S  URGER  V. 


treatment.  The  age  of  the  child  was  four  years,  and  the  difference 
in  time  between  the  two  casts,  two  months. 

There  are  certain  manifest  disadvantages  in  the  use  of  stiff  band- 
ages after  tenotomy. 

There  is^  no  method  of  correcting  the  position  given  by 
means  of  the  bandage,  except  by  the  removal  of  the  bandage  and 
the  application  of  another.  Great  care  should  be  exercised  in  the 
application  of  the  bandage,  and  the  retention  of  the  foot  in  an 
over-corrected  position,  until  the  plaster  bandage  is  thoroughly 
stiff.  This  requires  some  familiarity  with  the  use  of  stiff  bandages, 
as  speedy  hardening  is  essential  to  success.     The  details  of  the  ap- 


FiG.  446. — Bruns'  Club-foot  Shoe. 


Fig.  447. — Braatz  Appliance. 


plication  of  plaster  bandages  will  be  given  later,  in  speaking  of  the 
method  of  forcible  correction. 

The  advantage  of  the  method  is  chiefly  the  amount  of  comfort 
the  patient  finds  in  the  freedom  from.  pain.  If  the  bandage  is  well 
applied,  the  pressure  is  well  distributed  and  is  not  a  strap  or  a 
point  pressure,  but  the  foot  is  well  held  by  a  generally  distributed 
force. 

Other  forms  of  traction  appliances  are  illustrated  in  the  accom- 
panying cuts.  They  are  of  interest  as  showing  the  variety  of  ways 
in  which  a  pulling  force  can  be  applied. 

Fixation  after  tenotomy  is  also  done  by  means  of  stiff  bandages, 
starch  carefully  applied,  leather,  gutta  percha,  and  metal  splints, 
or  by  bandaging  the  foot  first  to  a  stiff  side  splint,  or  after  divi- 
sion of  the  tendo  Achillis  to  a  splint  holding  the  foot  in  a  corrected 
position. 


CL  un-Foo  T. 


479 


After  correction  of  the  varus  deformity  and  tlie  division  of  the 
tcndo  Achillis,  a  dorsal  splint  can  be  applied,  bent  to  a  right  angle 
and  the  foot  bent  to  this.  The  results  it  gives  can,  however,  be 
gained  by  simpler  means  less  annoying  to  the  patient  and  surgeon. 


Fig.  448.— Blanc's  Appliance. 


Fig.  451. 

Figs.  450,  451. — Gutter  Splints  for  Retention 

of  Club-foot  Appliance. 


Fig.  452. — Bandage  Ap- 
plied for  Correction. 


Fig.  453. — Correction 
by  Bandaging. 


Fig.  454. — Foot  before 
Bandaging. 


Fig.  455. — Foot  Bandaged 
to  a  Side  Splint. 


Scarpa's  Shoe  an^  Modifications. — The  Scarpa  shoe  as  it  is  at  pres- 
ent used,  has  been  modified  in  a  variety  of  ways,  so  that  it  hardly 
resembles  the  appliance  as  originally  devised. 

This  shoe  was  at  one  time  in  almost  universal  use.  but  all  the 
various  forms  are  clumsy  in  design  and  need  careful  adjustment. 


48o 


OR  THOPEDIC  S  UR  GER  V. 


Little's  modification  is  the  best  form  of  this  appHance.  The  shoe 
part  is  made  of  metal  well  padded ;  the  sole  is  divided  and  furnished 
with  a  pivot  so  that  the  front  part  of  the  sole  can  slide  to  the  side. 
The  heel  of  the  foot  is  kept  in  place  by  means  of  straps  which 
pass  over  the  instep  and  are  secured  to  the  bottom  of  the  heel  of 
the  shoe.  A  metal  spring  passes  forward  on  the  outer  side  and 
from  it  passes  a  strap  over  the  front  of  the  foot.  By  tightening 
this  strap,  the  fore  part  of  the  foot  is  turned  outward,  and  the 
force  in  the  opposite  direction  is  made  by  means  of  another  strap 
which  passes  around  the  ankle,  starting  from   and  secured  to  the 


Fig.  457. — Stroraeyer's  Apparatus  Applied. 


Fig.  458. — Stromeyer's  Appliance. 


inner  side  of  the  counter.  A  bent  spring  with  the  concavity  out- 
ward, on  the  outer  side  of  the  leg,  is  secured  to  the  shoe  below,  and 
if  strapped  to  the  leg  above,  tends  to  turn  the  foot  outward,  and  a 
screw  force  added  to  this  upright  is  intended  to  change  the  angle 
of  the  foot  to  the  leg  and  correct  the  equinus  deformity. 

Stromeyer's  appliance,  which  antedated  Little,  is  similar,  yet  more 
simple,  and  was  not  furnished  with  a  screw  force  at  the  ankle ;  but 
the  upright  (a)  was  checked  by  a  screw  (c)  and  the  sole  plate  (d) 
secured  to  the  side  spring  by  a  leather  piece  surrounding  spring. 

Adams  modified  the  Scarpa  shoe  by  omitting  the  side  spring, 
and  gave  the  lateral  motion  by  means  of  a  screw  force  applied 
under  the  joint  in  the  sole  {/),  the  strap  (e)  is  connected  with  the 
sole  plate  and  not   with   the  side  spring.        A  screw    at  £■  flexes 


CLUH-i'Oor. 


481 


or  extends  the  foot  and  by  the  apph'cation  of  an  additional  screw 
at  c,  the  sole  plate  {(.I)  can  be  made  to  turn  so  that  the  outer  edge 
is  made  higher  than  the  inner.     The   upright  ib)  is  armed  with   a 


\S 


Fig.  459.— Adams'  Correcting  Fig.  460.— Adams'  Correcting        Fig.  461.— Adams'  Correcting  Appli- 

Shoe.  Shoe.  ance  for  Infantile  Cases. 

padded  plate  («),  which  firmly  holds  the  leg.  In  some  forms  of 
the  appliance,  the  joint  at  /  can  be  made  to  raise  the  front  of  the 
foot  and  rotation  comes  at  the  joint. 

In  still  another  form,  rotation  around  the 
leg  is  prevented  by  carrying  the  appliance 
above  the  knee,  as  in  the  accompanying  pic-  t'.f^^'^P^^ 

ture ;  the  altering  screw  force  is  at  d. 


Fig.  462.— Tamplin's  Appliance.  Fig.  463.— Langgaard's  Shoe. 


Fig.  464. — Kolbe's  Shoe. 


Tamplin  modified  Little's  shoe.  The  straps  {c  and/)  press  the 
tarsus  inward,  the  spring  (/)  everts  the  foot ;  the  upright  {c)  and 
strap  {d)  hold  the  leg,  and  an  extra  strap  {g)  holds  the  leg  above 
the  ankle.  Screw  force  at  k  and  /  turns  the  sole  plate  outward, 
flexing  and  extending  it. 
31 


482  ORTHOPEDIC  SURGERY. 

Langgaard's  appliance  is  a  modification  of  that  of  Adams;  but 
the  rotating  and  everting  screw  is  placed  farther  behind  at  d. 

Another  form  of  the  screw-correcting  shoe,  known  as  the  Kolbe 
shoe,  is.  figured,  which  has  so  far  departed  from  the  type  of 
Scarpa's  shoe  that  but  little  remains.  It  is  important,  to  prevent 
rotation  of  the  appliance,  that  it  should  extend  above  the  knee. 

Many  objections  can  be  urged  against  correcting  appliances  of 
this  sort,  especially  the  constant  care  required,  and.  the  expense  of 
their  construction.  They  will,  however,  be  found  to  be  efficient  in 
competent  hands.  Correction  in  the  direction  of  abduction  will  be 
found  usually  a  matter  of  no  great  difificulty ,  the  elevation  of  the 
front  of  the  foot,  and  stretching  the  tendo  Achillis,  is  more  diffi- 
cult, but  can  be  accomplished  in  time  with  or  without  tenotomy. 
The  most  difficult  correction  to  be  brought  about  by  mechanical 
means  is  that  of  the  arch  of  the  foot,  and  in  some  instances  of  re- 
lapsed and  resistant  club-foot,  osteotomy  offers  the  only  method 
for  completely  accomplishing  this. 

Operative  Treatment  of  Club-Foot. 

In  severe  and  resistant  cases,  the  following  radical  measures 
have  been  employed: 

1st.  Open  incision. 

2d.  The  use  of  extrem.e  force. 

3d.  Tarsal  osteotomy. 

4th.  Tarsal  resection. 

The  chief  difficulty  is  in  obstinate  cases  to  stretch  the  contracted 
tissue  on  the  concave  side  of  the  distortion.  Acting  on  this  belief, 
Dr.  A,  M.  Phelps  has,  by  a  direct  open  incision  on  the  inner 
and  plantar  surface,  corrected  severe  cases,  and  has  favored  this 
method  of  treatment. 

The  advantage  of  open  incision  in  club-foot  is  the  facility  of 
complete  and  thorough  division  of  all  the  soft  tissues  to  the  bone. 
The  method  by  which  this  is  done  is  as  follows :  The  skin  is  divided 
along  the  inner  side  of  the  foot,  from  the  top  of  the  malleolus, 
well  down  on  the  inner  edge  of  the  first  metacarpal  bone.  After 
the  skin  is  incised,  the  other  tissues  are  cut  with  care,  using  a 
director  if  necessary.  The  insertion  of  the  tibialis  tendon  is  found 
and  cut  across.  The  artery  can  be  spared  by  careful  dissection, 
but  if  necessary,  it  can  be  divided  and  tied.  The  plantar  fascia 
on  the  sole  of  the  foot  should  be  divided  by  the  use  of  a  tenotome, 
or  long  thin  knife.  A  cross  incision  toward  the  sole  of  the  foot 
from  the  middle  of  the  long  incision,  is  sometimes  necessary,  but  it 

^N.  Y.  Med.  Rec,  Aug.  13th,  1881,  p.  169. 


CLVn-FOOT. 


483 


is  desirable,  if  possible,  to  avoid  this.  The  foot  is  then  brought  into 
as  normal  a  position  as  possible,  thorough  aseptic  dressings  are 
applied,  and  the  foot  is  then  fixed  in  a  plaster-of-Paris  bandage. 

Of  this  method  it  may  be  said,  that  healing  by  organized  blood 
clot,  is,  to  those  who  are  proficient  in  aseptic  surgery,  certain,  and 
the  method  is,  therefore,  free  from  danger." 

There  is,  however,  an   advantage  in   leaving  the  skin  of  the  sole 


Fig.  465. — Lever  Correction  Apparatus  (Applied). 

and  the  side  of  the  foot  undivided.     It  can  be  stretched  and  if  not 
incised,  leaves  no  scar. 

The  Use  of  Extreme  Force. — Many  of  the  ligaments  which  retain 
the  bones  in  their  distorted  position  are  beyond  convenient  reach 
of  the  knife;  it  is,  therefore,  advisable,  when  the  patients  are  under 
an  anaesthetic,  to  stretch  such  contracted  ligaments  as  cannot  be 
divided.     If  this  is  done  under  an  anaesthetic,  the  patient  is  saved 


Fig.  466.—^,  Diagram  of  Half-Circle.  Fig.  467.— C,  Sole  Plate. 

much  pain  and  time.  The  chief  difificulty  is  that  of  applying  the 
force  directly,  as  it  is,  owing  to  the  shape  and  size  of  the  foot, 
almost  impossible  to  twist  it  by  the  use  of  the  operator's  hands 
alone,  in  such  a  way  as  to  stretch  the  resisting  ligaments. 

A  simple  and  a  thoroughly  efficient  means  of  forcible  correction  is 
indicated  >n  the  accompanying  illustrations  (Figs.  465, 466,  467,  468.) 

A  steel  bar  is  applied  to  the  inner  side  of  the  foot,  long  enough 

'  Phillipson:  D.  Zeitschr.  f.  Chir. ,  xxviii. 


484 


ORTHOPEDIC  SURGERY. 


to  give  sufficient  leverage  for  efficient  force.  A  curved  half-circle 
of  steel,  A,  can  be  slipped  on  to  this  bar  and  by  screw  force  made 
to  press  on  the  outer  and  upper  side  of  the  astragalus  (passing 
under  the  foot).  The  front  of  the  foot  rests  on  a  sole  plate,  C, 
which  presses  on  the  inner  side  and  extends  on  the  sole  to  the 
proximal  end  of  the  cuboid,  but  not  to  the  os  calcis.  This  sole 
plate  is  also  slipped  upon  the  bar  and  a  short  steel  arm,  B,  adjust- 
able by  screw,  exerts  pressure  on  the  top  of  the  foot.  If  the 
screws  are  sufficiently  tightened,  the  foot  will  be  held  securely  as 
in  a  vice,  and  by  moving  the  bar,  the  front  of  the  foot  can  be 
twisted  outward  and  upward,  the  astragalus  being  the  fulcrum 
on  which  this  force  is  applied. 

The  first  mechanical  means  of  value  for  the  purpose  of  immedi- 
ately correcting  obstinate  club-foot  was  reported  by  Dr.  Morton, 


Fig.  468.— Section  of  Plate. 


Fig.  469.— Morton's  Club-foot  Stretcher. 


of  Philadelphia.  The  appliance  seemed  to  be  defective  in  that  it 
lacked  precision,  relying  as  it  did  for  the  correcting  force  upon 
straps,  which  are  liable  to  stretch  and  slip.  The  accompanying 
drawing  illustrates  an  appliance  which  appeared  to  remedy  this 
difficulty  (Figs.  470,  471).' 

The  object  of  the  appliance  is  to  exert  pressure  under  control  of 
the  operator  in  three  directions,  and  also  to  enable  him  to  twist 
and  raise  the  front  of  the  foot. 

In  operating  upon  obstinate  cases  of  club-foot  (the  only  cases  for 
which  this  method  is  designed)  the  method  of  procedure  is  as  fol- 
lows: Tenotomy  is  performed  in  the  usual  way,  the  plantar  fascia 
divided  first,  the  tibialis  tendons  (if  contraction  is  present)  and  the 
tendo  Achillis  last  (after  the  deformity  at  the  arch  of  the  foot  has 
been  in  a  degree  corrected) ;  the  foot  is  then  forcibly  manipulated 
with  the  hands,  pressure  being  exercised  upon  the  projecting  head 

'  Boston  Med.  and  Surgical  Journal,  1881,  p.  241. 


CLUJ1-J'()i)7'. 


485 


of  the  astragalus  by  the  thumbs,  and  force  applied  in  a  counter- 
direction  by  the  hands  grasping  the  ankle  and  fore  part  of  the  foot. 
It  will  be  found  in  certain  cases  that  complete  correction  of  the 
deformity  cannot  be   accomplished   by  the   hands   alone,  and   the 


Fig.  470. — Club-foot  Stretcher. 

hindrance  will  be  seen  to  be  not  a  shortened  tendon  or  any  tissue 
accessible  to  the  tenotome. 

The  instrument  described  is  then  to  be  applied,  and  the  foot 
fo-rcibly  wrenched  into  an  over-corrected  position.  An  anesthetic 
is  of  course  required,  and  correction  will  be  done  gradually  rather 
than  by  any  sudden  tear.     The  extent  to  which  force  can  w4th 


Fig.  171. — Club-foot  Stretcher  Applied. 


safety  be  applied  is  with  difficulty  defined ;  it  may  be  said,  how- 
ever, that  experience  shows  that  a  much  greater  pressure  can  be 
used  than  would  at  first  be  thought  feasible — in  a  majority  of  cases 
enough  force  can  be  used  to  convert  the  foot  from  the  position  of 
varus  to  that  of  valgus,  and  to  correct  the  equinus  position.     In 


486 


ORTHOPEDIC  SURGERY. 


the  simpler  cases,  this  is  always  possible ;  in  the  severer  cases  some 
minutes  should  be  given  to  gradually  stretch  the  foot.  Sometimes 
complete  correction  is  not  possible  at  one  sitting,  and  something 
will  have  to  be  left  for  after-treatment  or  foi;  a  second  sitting. 

After  the  foot  has  been  brought  into  a  position  which  is  nearly 
normal,  and  the  contracted  tissues  so  stretched  that  the  foot  can 
be  held  without  a  great  amount  of  force,  the  foot  should  be  fixed 
in  the  corrected  position.  For  this  purpose,  nothing  is  as  useful 
as  a  plaster-of-Paris  bandage  properly  applied.  The  foot  should 
be  held  in  as  nearly  a  normal  position  as  is  possible,  grasped  by 
one  hand  at  the  toes,  while  counter-pressure  is  exerted  on  the  leg. 

Roller  plaster  bandages,  prepared  in  the  way  that  is  customary 
for  plaster  jackets,  are  wound  around  the  foot  and  leg,  which  are 
first  to  be  covered  with  one  layer  of  sheet  wadding.  The  band- 
ages are  to  be  applied  without  loosening  the  hold  upon  the  foot, 
which  is  to  be  kept  in  the  corrected  position  until  the  bandages 
have  become  sufficiently  hard  not  to  yield  when  the  hold  on  the 
foot  is  loosened,  and  additional  turns  are  then  applied  around  the 
toes.  The  bandage  should  be  carried  above  the  knee  and  half-way 
up  the  thigh,  and  the  leg  should  be  flexed  at  the  knee,  thus  pre- 
venting .any  subsequent  rolling  of  the  limb  in  the  plaster  bandage. 

There  should  be  no  wrinkles  in  the  bandage,  and  no  pressure 
should  be  made  upon  the  dorsum  of  the  foot  while  the  gypsum 
dressing  is  hardening.  Aften  ten  days  or  three  weeks,  the  stiff 
bandage  may  be  removed,  and  if  the  foot  is  sufficiently  corrected  a 
walking  shoe  applied.' 

The  chief  objection  which  will  be  urged  against  this  method  will 
be  the  supposed  risk  incurred.  It  would  seem,  however,  that  the 
danger  is  not  no  so  great  as  would  be  thought.  Experience  with 
osteoclasis  has  proved  conclusively  that  the  temporary  pressure 
upon  the  skin  necessary  to  break  bone  does  not  cause  sloughing  or 
even  an  abrasion ;  the  same  is  true  of  the  pressure  required  to 
rectify  a  club-foot.  Experience  has  also  proved  that  it  is  safe  to 
fix  a  limb  with  plaster-of-Paris  bandage  immediately  after  osteo- 
clasis. The  same  appears  to  be  the  case  in  club-foot,  if  ordinary 
care  is  used  in  applying  the  bandages.  Sloughs  may  occur  on  the 
inside  of  the  ball  of  the  toe,  on  the  outer  and  under  side  of  the 
sole,  and  on  the  dorsum  of  the  foot;  but  these  sloughs  are  not 
more  troublesome  than  those  sometimes  occurring  in  the  use  of 
Scarpa's  shoe  or  appliances  held  by  straps,  and  they  are  not  so 
liable  to  occur,  from  the  fact  that  in  a  foot  held  in  a  well-applied 
plaster-of-Paris    bandage,  the    pressure   is   not    confined   to  a  few 

'  Hahn,  Berl.  klin.  Woch.,  March  19th,  1883,  describes  a  new  method  of  holding  the 
foot  while  a  planter  bandage  is  applied. 


C7M/l-/''0OT.  487 

points,  but  is  nearly  uniform  over  the  whole  foot.  In  case  a  slouch 
appears,  the  followin^r  appliance  (Fig.  472;  can  be 'used  until  the  skin 
has  recovered,  so  that  a  plaster  bandage  can  again  be  reapplied  if 
a  second  one  is  necessary.  A  plaster  bandage  is  applied  in  the 
ordinary  way  from  the  lower  part  of  the  leg  above  the  malleoli  to 
above  the  knee,  which  should  be  bent ;  a  strip  oi  strong  iron  rod  is 
placed  on  the  first  layer  of  the  bandage,  bent  at  the  top  so  as  to  half 
encircle  the  thigh,  to  pass  along  the  outer  side  of  the  leg,  and  to 
project  slightly  above  and  to  the  outer  side  of  the  outer  edge  of  the 
foot.  At  the  lower  end  of  this  rod  a  buckle  is  attached,  and  the  por- 
tion lying  upon  the  plaster  bandage  is  thoroughly  incorporated  by  the 
successive  turns  of  the  bandage.  A  strip  of  rubber  adhesive  plaster 
is  wound  around  the  foot  (which  can  be  protected  in  the  sole  by  card- 
board if  necessary),  and  to  the  free  end  of  the  plaster  at 
the  level  of  the  terminal  end  of  the  fifth  metacarpal  a  -;==^^^^^^^^^^ 
piece  of  webbing  is  sewn.  This  is  to  be  secured  to 
the  buckle  attached  to  the  iron  rod.  Other  strips  of 
webbing  and  other  buckles  can,  if  needed,  be  put  at  any 
desired  point,  and  by  a  wrench  the  iron  can  be  bent 
in  any  direction,  so  that  the  point  from  which  the  pull 
is  to  proceed  can  be  placed  at  any  desired  direction; 
additional  strips  of  iron  rod  can  also,  when  necessary, 
be  applied.  It  is  of  course  desirable  to  prevent  the 
whole  appliance  from  slipping  down,  and  this  can  be  _/  (  \ 
done  by  placing  a  long  strip  of  adhesive  plaster  on  the  ^"^"^^^ 
skin  of  the  leg  before  the  gypsum  bandage  is  applied,  Fig. 472— Trac- 
and  a  buckle  on  the  outside  of  the  bandage;  if  the  free  ''°"  ppiance. 
end  of  the  plaster  is  secured  in  the  buckle,  slipping  of  the  appliance 
down  is  prevented.  A  stocking  and  slipper  can  be  worn  on  the 
foot  if  a  hole  is  cut  in  the  side  for  the  strip  of  webbing  to  pass 
through,  and  the  patient  can  bear  weight  upon  the  foot. 

Wolff '  reports  success  in  the  treatment  of  club-foot,  by  forcible 
manual  correction,  preceded  or  not  by  tenotomy  of  the  tendo 
Achillis  and  followed  by  immediate  fixation  in  silicate  of  potash 
bandages,  reinforced  during  the  time  necessary  for  the  hardening 
of  the  silicate  by  plaster  bandages.  The  plaster  is  removed  and 
the  silicate  bandage  worn  continuously  for  several  months,  no  other 
appliance  being  necessary.  Several  operations  may  be  required  in 
severe  cases."" 

In  cases  of  the  ages  of  twenty,  eleven,  and  five,  reported  correc- 
tion was  speedily  effected  in  three  weeks'  time. 

The  writers  would  most  thoroughly  concur  in  Wolff's  statement, 

'  Wolff:  Berliner  klinische  Wochschr. ,  1885,  Nos.  11  and  12. 
=  Wolff  :  Langenbeck's  Archiv,  33d  Bd. ,  ist  Heft. 


488 


ORTHOPEDIC  SURGERY 


that  forcible  rectification  is  able  to  correct  and  cure  the  severest 
forms  of  club  foot,  but  they  have  found  mechanical  correction 
more  reliable  than  simple  manual  force 


"IT 


\ 


in 


Fig.  473. — Foot  Before  Correction. 


Fig.  474.  Fig.  475. 

Figs.  474,  475. — Foot  After  Correction. 


The  accompanying  cuts  (Figs.  473  to  478)  indicate  relapsed  and 
resistant  cases  of  congenital 
club-foot.  The  boy  was  four- 
teen years  of  age;  the  foot 
was  corrected  at  one  sitting, 
necessitating  the  use  of  a 
plaster  bandage  to  the  cor- 
rected foot  for  two  months. 
A  walking  appliance  was  fur- 
nished and  no  further  treat- 
ment other  than  occasional 
inspection  for  six  months 
was  necessary,  and  the  cure 
had  remained  permanent 
when  last  heard  from,  three 
years  later. 


Fig.  476. — Foot  Before  Correction 


Fig.  477. — Result  of  Correction. 


CL  un-i'oo  T. 


489 


The  cast  of  the  girl's  foot  was  taken  at  the  age  of  ten.  Two 
rectifications  were  needed  and  a  direct  treatment  of  four  montiis. 
The  drawings,  from  a  photograph,  indicate  the  condition  of  the  feet 
when  the  child  was  at  the  age  of  tliirteen,  no  appliance  having 
been  worn  for  two  years.' 

In  applying  the  bandages,  it  is  of  course  important  that  the  foot 
should  be  held  in  a  corrected  position,  or  an  over-corrected  position, 
until  the  plaster  becomes  hard,  as  no  further  correction  can  take 
place  under  the  bandage.  In  the  majority  of  cases  perfect  correction 


Fig.  478. — Side  View  Showing  Amount  of  Motion  at  Ankle. 

or  over-correction  is  possible,  and  the  foot  can  be  held  in  proper  po- 
sition for  the  application  of  the  fixation  bandage  without  much  force. 
Krauss,  as  an  aid  to  support  by  plaster  bandages,  makes  use  of  a 
wooden  sole  plate  with  a  steel  upright  on  the  inner  side  of  the  leg 
and  an  arrangement  for  increasing  the  pressure  for  the  inner  side 
of  the  metatarsal  and  great  toe.  The  appliance  is  covered  with 
thick  felt  and  the  foot  and  ankle  secured  to  the  wooden  sole  plate 
by  means  of  a  plaster-of-Paris  bandage  applied  over  a  stocking, 
and  without  much  cotton  applied  to  the  foot.     Correcting  screw- 

'  Wolff  uses  the  silicate  bandage  as  a  walking-appliance,  but  it  is  manifestly  more 
cumbersome  and  unsightly,  and  therefore  less  useful  than  the  Taylor  varus  shoe. 


490 


ORTHOPEDIC  SURGERY. 


pressure  is  exerted  upon  the  foot,  also  secured  by  plaster-of-Paria 
bandages. 

A  means  of  fixation  after  forcible  rectification  is  recommended 
by  Hahn.  It  will  be  readily  understood  by  the  accompanying 
illustration  (Fig.  479).  A  T-shaped  piece  of  wood  is  incorporated 
in  the  plaster  bandage  and  by  means  of  it  the  foot  is  twisted  and 
held  in  a  correct  position  while  the  plaster  is  setting. 

Stillman  reports  a  method  of  correction  by  means  of  a  "  tractor 
rectifier  "  (Fig.  480).  The  foot  is  corrected  manually  and  retained 
as  corrected  by  means  of  articulating  fenestrated  steel  rods  with 
sector  attachments,  which  can  be  secured  at  different  angles. 

Thomas,  of  Liverpool,  has  devised  a  gimple  and  excellent  wrench 


Fig.  479.— Hahn's  Method  of  Holding  the  Foot  during 
Application  of  Plaster  Bandages. 


Fig.  480 


for  twisting  club-foot,  which  Gibney  has  employed  with  success. 
It  consists  of  a  monkey  wrench  with  two  arms  (bent  to  conform 
to  the  dorsum  and  sole  of  the  foot)  secured  at  right  angles  to  each 
of  the  jaws  of  the  wrench.  The  foot  can  be  held  by  the  wrench 
and  twisted.     The  writers  have  used  it  with  advantage. 

Excision  of  the  Tarsus. — ^Dr.  Little,  of  London,  was  the  first  to 
suggest  removal  of  a  portion  of  the  tarsus  (the  cuboid  bone)  as  a 
means  of  shortening  the  treatment  in  "  inveterate  varus." '  This 
was  done,  in  1854,  by  Mr.  Solly,  of  St.  Thomas's  Hospital,  at  the 
recommendation  of  Dr.  Little ;  the.  result  was  less  successful  than 
was  anticipated,  owing,  apparently,  to  the  difficulty  encountered  in 
maintaining  the  corrected  position  of  the  foot  by  means  of  the  ap- 
pliances used.     The  patient  recovered  from  the  operation. =     Mr. 

*  "  Practical  Observations  on  the  Treatment  of  Club-Foot,"  third  edition,  p.  305. 
=  Adams:   "Club-Foot,"  second  edition,  Philadelphia,  p.  251. 


L7 A/ /,'-/•■()()  T.  491 

Lund'  removed  the  astragalus  in  a  similar  case  with  success.  The 
details  have,  however,  not  been  yiven  with  sufficient  accuracy  to 
justify  a  clear  opinion  as  to  the  perfection  of  the  cure.  Dr.  Mason, 
of  New  York,  was  obliged  to  amputate  in  a  case  where  he  had 
unsuccessfully  excised  the  astragalus-  and  a  portion  of  the  external 
malleolus.  Verbelzi  successfully  dissected  out  the  astragalus  in 
a  case  of  congenital  club-foot  in  a  child  five  and  one-half  years 
old.^     The  exact  details  it  has  not  been  possible  to  find. 

Mr.  Lund  showed  before  the  London  Clinical  Society  a  case 
where  he  had  successfully  removed  the  astragali  in  double  congen- 
ital talipes.  The  boy  was  able  to  walk  about  readily.  The  astrag- 
alus was  excised  (after  an  incision  through  the  soft  parts)  by  means 
of  a  gouge  and  a  short  curved  hook,  with  a  cutting  edge  on  its 
concavity.  Mr.  Thos.  Smith  and  Prof.  John  Wood  have  also  per- 
formed the  operation  successfully.'*  Mr.  Davy^  has  operated  in 
three  cases  by  removing  simply  the  cuboid  bone,  and  in  three  cases 
by  excising  a  wedge-shaped  piece  from  the  tarsal  arch.  Death  from 
septicaemia  occurred  in  one  case.  In  the  others  recovery  took 
place,  and  from  the  report  the  cases  progressed  favorably. 
Davies  Colley  operated  by  resection  of  the  tarsal  bones  on  a 
child  twelve  years  old ;  ten  days  after  the  operation  on  the  second 
foot,  and  twelve  weeks  after  the  first  operation,  the  patient  was 
able  to  walk  about  without  any  apparatus.  Two  months  later, 
when  re-examined  (no  apparatus  having  been  worn  in  the  interval), 
the  foot  was  found  in  good  position,  the  boy  treading  on  the 
whole  of  the  sole.  The  patient  could  walk,  hop,  and  jump.  Six 
months  later  he  was  able  to  walk  eight  miles.' 

Konig/  Rupprecht,'  Mensel "  report,  respectively,  three,  five,  and 
five  operations  of  resection  of  the  tarsus  for  severe  club-foot.  All 
are  mentioned  as  successful  with  the  exception  of  one  under  the 
care  of  Konig,  where  death  occurred  ten  days  after  the  operation. 
At  the  autopsy  it  was  found  that  the  patient  had  been  suffering 
from  ulcerative  endocarditis,  with  valvular  disease  of  the  heart, 
and  with  pathological  changes  in  the  lungs." 


'  British  Medical  Journal,  October  19th,  1S72.    , 
=  New  York  Medical  Record,  July  14th,   1877. 

3  Centralblatt  f.  Chirurgie,  No.  24,  1877. 

4  Lancet,  March  i6th,  1878,  p.  389. 

5  Lancet,  Feb.  14th,  1SS8. 

*  Lancet,  March  i6th,  187S,  p.  388;  British  Medical  Journal,  Dec.  15th,  1877. 

'  Medico-Chirurgical  Transactions,  second  series,  vol.  xliii.,  1S77. 

^  Centralblatt  f.  Chirurgie,  18S0,  No.  13. 

9  Ibid  ,  March  13th,  1880. 
'°  Centralblatt  f.  Chirurgie,  No.  11,  iSSo. 
"  Poore  :  Annals  of  Surgery,  March,  18S6,  p.  206. 


492 


ORTHOPEDIC  SURGERY. 


The  methods  introduced  may  be  grouped  as  follows: 

1.  Removal  of  the  cuboid  alone. 

2.  Removal  of  the  astragalus  alone. 

3.  Removal  of  the  astragalus  and  cuboid  and  scaphoid. 

4.  Section  of  the  neck  of  the  astragalus. 

5.  Removal  of  the  astragalus  and  the  external  malleolus. 

6.  Osteotomy  of  the  lower  end  of  the  tibia  and  fibula. 

7.  Wedge-shaped  resection  of  the  tarsus. 

The  results  from  the  first  method  have  not  been  altogether  satis- 
factory, and  the  fourth  may  be  said  to  be  insufificient ;  and  against 
the  third  and  sixth  it  may  be  urged  that  too  much  mutilation  of 
the  foot  is  required. 

Authorities  differ  in  advocacy  of  the  second  and  seventh  methods. 

The  details  of  the  pro- 
cedure of  excision  of  the 
tarsus  in  club  -  foot  are 
simple. 

An  Esmarch  bandage  is 
applied  to  the  foot,  and  an 
incision  is  made  along  the 
outer  border,  from  the  mid- 
dle of  the  OS  calcis  to  the 
middle  of  the  fifth  meta- 
tarsal bone.  This  is  joined 
at  right  angles  by  another 
incision  across  the  dorsum 
of  the  foot.  The  soft  parts 
being  reflected,  the  cu- 
boid is  first  removed,  then 
a  wedge-shaped  portion  of 
the  tarsus  is  excised  of 
sufficient  size  to  allow 
the  foot  to  be  brought  into  position  without  much  force.  The 
wedge  of  bone,  which  may  be  removed  with  a  chisel  or  saw,  should 
have  its  base  of  a  width  corresponding  to  that  of  the  cuboid  and 
should  be  rather  thicker  above  than  at  its  lower  surface.  The 
operation  should  be  performed  with  the  strictest  antiseptic  precau- 
tions. After  it  the  foot  should  be  held  in  a  corrected  position  and 
fixed  by  means  of  a  plaster-of-Paris  bandage,  or  some  other  efficient 
form  of  fixative  appliance. 

In  the  place  of  plaster  of  Paris  as  a  means  of  fixation  after  tarsal 
resection,  the  writers  have  used  a  wire  splint  made  by  bending 
strong  iron  wire  as  indicated  in  the  accompanying  drawing.  Pieces 
of  tin  are  soldered  on  at  the  foot  piece  and  upper  part  of  the  thigh. 


Fig.  481.— Wire  Splint  for 
Fixation  of  Club-foot  after 
Excision. 


Fig.  482.— Wire  Splint 
Applied. 


LLUH-I'UOT.  493 

The  foot  can  be  kept  in  place  by  adhesive  plaster.  Inversion  of 
the  limb  is  prevented  by  winding  plaster  strii)S  around  the  leg 
and  thigh,  and  fastening  the  free  end  to  the  wire  si^lint;  tlie  heel 
can  be  kept  down  by  adhesive  strips  along  the  sides  of  the  leg, 
secured  to  the  bottom  of  the  sole  plate.  No  dorsal  pressure  is 
required,  and  the  whole  can  be  covered  by  a  bandage.  Eversion  of 
the  foot  can  be  obtained  by  a  strap  around  the  front  of  the  foot 
between  the  sole  and  sole  plate  and  secured  to  the  side  arm. 

Krauss '  expresses  well  the  objections  against  tarsal  resection  as 
a  means  of  treatment  for  inveterate  club-foot  as  follows:  {\)  The 
different  methods  of  resection  of  the  tarsus  impair  the  form  of  the 
foot  and  the  stability  of  its  osseous  arch,  with  a  consequent  impair- 
ment of  mobility  and  usefulness.  (2)  Resection,  as  an  operation, 
is  not  free  from  risk.  (3)  The  extirpation  of  the  astragalus  is  a 
more  suitable  operation  for  restoring  the  form  of  the  foot  than 
the  removal  of  a  wedge  in  the  direction  of  the  medio-tarsal  joint; 
but  it  leaves  an  immovable  ankle,  or  one  partly  so,  a  weak  union 
between  the  os  calcis  and  the  second  row  of  tarsal  bones,  and 
serious  shortening  of  the  foot.  (4)  Resection  removes  all  chance 
of  future  restoration  by  orthopedic  treatment.  (5)  "  There  is  no 
conceivable  form  of  club-foot  in  which  tarsal  resection  is  justifia- 
ble, except  it  be  in  the  case  of  one  that  is  persistently  painful  in 
an  old  subject,  and  in  which  there  is  no  prospect  of  a  good  result 
from  orthopedic  treatment.  In  such  a  case  resection  may  be  fairly 
tried,  instead  of  amputation." 

Wolff  claims  that  the  successful  results  after  resection  of  the 
astragalus  are  not  due  strictly  to  the  removal  of  the  bone.  An 
examination  of  the  bones  of  a  pronounced  case  of  talipes  equino- 
varus  will  show  that  the  astragalus  is  not  the  only  bone  which  is 
misshapen,  but  that  all  the  bones,  with  the  exception  of  the  meta- 
tarsal and  phalangeal  bones,  are  altered  in  their  shape.  For  an 
equal  reason,  Phelps'  direct  incision  is  to  be  rejected  as  unnec- 
essary and  unsurgical,  as  well  as  a  wedge-shaped  resection  or 
osteotomy. 

Wolff  claims  that  equally  good  and  more  rapid  cures  can  be 
effected  by  bloodless  "  redressement  "  of  the  foot,  this  being  pos- 
sible not  only  in  the  deformed  feet  of  children  but  also  of  adults. 

Although  tarsal  resection  is  a  procedure  Avhich  will  cure  club- 
feet at  the  expense  of  exposure  to  a  small  amount  of  risk  and  at 
the  saving  of  time,  its  field  of  usefulness  should  be  kept  a  limited 
one. 

The  writers  have  been  enabled  to  obtain  a  number  of  excellent 
results  and  have  experienced  no  drawbacks  in  performing  this  ope- 
'  Fifteenth  Cong-.  Germ.  Surgf.  Soc. 


494 


ORTHOPEDIC  SURGERY. 


ration  in  a  number  of  cases.  The  illustration  represents  an  entirely 
satisfactory  result,  the  condition  prior  to  operation  in  the  instance 
of  a  boy  of  fourteen  is  indicated  in  the  drawings  from  the  casts  2 
and  4,  and  the  result  of  the  operation  by  drawing  from  the  cast  i 
and  3.  Both  feet  were  operated  upon  and  the  functional  result  may 
be  determined  by  the  illustration  reproduced  from  the  photograph 
(Fig.  484).  It  may  be  added  that  the  boy  was  seen  at  the  age  of 
nineteen  and  had  been  able  for  several  years  to  engage  in  an  active 

occupation,  and  was 
able  to  walk  without 
cane  or  ankle  appli- 
ance five  or  ten  miles. 
Such  results  corre- 
spond with  those  of 
others;  but  it  can- 
not be  denied  that 
much  of  the  foot  is 
sacrificed,  and  that 
the  severest  cases  can, 
as  a  rule,  be  perfect- 
ly corrected  without 
such  radical  proced- 
ure. The  method  does, 
however,  save  time  in 
treatment,  and  when 
time  and  expense  are 
to  be  considered,  the 
procedure  should  be 
regarded  as  efificient 
and  without  great  risk. 
Astragaloid  Osteotomy. — An  examination  of  the  anatomy  of  re- 
sistant club-foot  shows  that  the  facet  of  the  astragalus  in  the 
astragalo-scaphoid  articulation  is  on  the  side  instead  of  in  front. 
There  is  also  some  obliquity  of  the  neck  of  the  astragalus.  If 
this  obstruction  of  the  bone  can  be  corrected  and  the  front  of 
the  foot  brought  into  .place,  there  would  be  no  tendency  to  re- 
lapse. 

It  is  essential,  in  every  inveterate  case  of  club-foot,  that  if  the 
foot  is  to  be  unfolded,  the  shortened  tissues  in  the  arch  of  the  foot 
and  in  the  inner  side  of  the  foot  be  stretched,  torn,  or  divided. 
This  can  be  done  safely  by  means  of  tenotomy,  forcible  stretching, 
or  open  incision;  but  the  deformity  of  the  astragalus  still  remains. 
In  a  great  majority  of  cases,  if  the  deformity  is  rectified  and  the 
foot  held  a  sufificient  time  in  the  proper  position,  and  a  proper 


Fig.  . 


-Drawn  from  Casts  Before  and  After  Excision, 
before  excision;  i  and  3,  after  excision. 


2  and  4, 


CLUJi-J-UUT. 


495 


walking  shoe  used  for  a  year,  a  new  facet  of  the  astragalus  will  be 
formed  and  a  cure  effected.  In  a  few  cases  this  is  not  the  case, 
and  in  such  instances,  osteotomy  of  the  neck  of  the  astragalus  sug- 
gests itself  as  a  suitable  operation. 

The  procedure  will  not  be  found  a  difficult  one.  Tenotomy  and 
division  of  the  fascii  and  ligaments  should  be  done,  and  the  foot 
stretched  and  manipulated  into  as  nearly  normal  a  position  as  pos- 
sible. An  incision  through  the  skin  is  made  from  the  tip  of  the 
malleolus  to  the  inner  side  of  the  head  of  the  first  metatarsal, 
which  will  be  found  in  severe  cases  close  to  the  malleolus.  The 
incision  is  close  to  and  nearly  parallel  to  the  tibialis  anticus  tendon, 


Fig.  484. — From  Photograph  Two  Years  After  Excision. 


Fig.  485. — Alteration  of  the  As- 
tragalo-Scaphoid  Articulation  in 
Club-foot.  Seven  months'  foetus. 
End  of  scaphoid  articulates  with 
end  of  tibia.     Prom  dissection. 


and  in  the  direction  of  the  metatarsal.  The  incision  should 
be  made  to  the  bone,  and  the  foot  straightened,  as  the  meta- 
carpal bone  is  separated  from  the  malleolus.  The  scaphoid  will  be 
seen  before  the  astragalus  is  encountered,  if  the  deformity  is  great, 
and  it  will  be  first  within  the  reach  of  the  knife  in  all  cases.  If  the 
foot  is  still  further  stretched,  the  scaphoid  begins  to  uncover  the 
side  of  the  astragalus,  and  the  neck  of  the  astragalus  is  seen ;  a 
small  osteotome  is  entered  and  placed  upon  the  neck  of  the  astrag- 
alus, to  the  distal  side  of  the  scaphoid  articulation,  and  as  in  the 
McEwen  operation,  the  neck  of  the  astragalus  divided  or  nearly 
divided.  The  foot  is  then  forcibly  straightened,  and  the  neck  of 
the   astragalus  unchiselled   is  fractured.     The  result  is  similar  to 


496 


OR  THOPEDIC  S  UK  GER  V. 


that  in  McEwen's  operation  for  knock-knee,  and  the  distortion  at  the 
neck  of  the  astragalus  is  removed.  It  is  manifest  that  the  Hne  of 
section  of  the  bone  at  the  neck  of  the  astragalus  should  be  trans- 
verse to  the  axis  of  the  bone,  and  at  such  a  plane  that  when  the 
equinus  deformity  is  corrected,  the  resulting  gap  at  the  section 
should  not  be  greater  than  necessary.  Strict  asepsis  is  essential. 
The  foot  should  be  fixed  in  a  corrected  position. 

Osteotomy  of  the  outer  corner  of  the  os  calcis  near  its  articula- 
tion with  the  cuboid  may  also  be  needed. 

It  will  not  be  found  a  substitute  for  tarsal  resection,  but  it  will 
be  found  useful  in  cases  where  the  head  of  the  astragalus  is  promi- 
nent and  twisting  of  its  neck  evident;  and  in  some  instances  of 
severe  distortions,  the  mutilation  inherent  to  tarsal  resection  will 
be  avoided. 

Osteotomy  may  also  be  performed  by  inserting  the  chisel  on  the 


Fig.  486.— Obliquity  of  Neck  of 
Astragalus. 


Fig.  487. — Dissection  of  Severe  Club-foot,  Showing  Relation 
of  Scaphoid  to  Astragalus.     From  Photograph. 


outer  side  of  the  foot,  and  in  some  cases  an  osteotomy  of  the  os 
calcis  near  its  articulation  with  the  cuboid  may  be  necessary. 

The  exact  value  of  astragaloid  osteotomy  cannot  yet  be  deter- 
mined, as  the  method  is  a  new  one. 

The  writers  have  obtained  a  most  excellent  result  in  one  case; 
curing  at  one  operation  an  inveterate  case  in  a  boy  of  ten.  The 
time  required  for  treatment  was  simply  the  time  for  operation  and 
the  necessary  healing  of  the  wound,  which  was  not  more  than  three 
weeks.  After  this,  the  patient  was  discharged  from  the  hospital 
and  not  seen,  except  once  for  inspection,  until  a  year  later.  No 
appliance  was  worn  except  a  plaster  bandage  for  a  month.  A 
year  later,  the  foot  was  found  functionally  perfect,  as  v/ell  as  in 
position  and  shape.  No  bone  had  been  sacrificed  and  the  danger 
of  the  procedure  was  slight.  In  three  subsequent  cases  in  smaller 
children,  the  result  was  not  so  perfect,  and  it  appeared  to  the  writers 


CLUH-J'OOT. 


497 


that  the  difficulty  lay  at  present  in  a  lack  of  precision  in  the  direc- 
tion of  the  insertion  of  the  osteotome,  which  in  one  case  was  so 
applied  as  to  properly  (livi<le  the  neck  of  the  astragalus,  but  in  later 
cases  was  not  accurately  done.  It  is  to  be  hoped  that  increased 
experience  may  develop  the  procedure,  as  it  would  appear  theoret- 
ically was  possible. 

Walking  Appliances,  Retentive  Appliances. — Whatever  method  of 
treatment  be  employed,  some  form  of  appliance  will  be  needed 
after  correction  to  retain  the  tarsal  bones  in  proper  position  until 
the  muscles  and  ligaments  have  adapted  themselves  to  the  normal 
position,  and  until  articular  facets  have  been  formed  in  the  proper 
direction,  or  the  astragalus  and  os  calcis  have  assumed,  under  altered 


Fig.  488. — Walking  Appliance 
with  Catch  at  Knee. 


Fig.  489. — Retention  Appliance    Fig.  490. — Walking  Appliance  with 
to  be  Worn  Inside  Shoe.  Attachment  for  Eversion. 


pressure,  a  relatively  normal  shape.  It  is  manifest  that  a  retention 
appliance  is  needed  for  a  shorter  time  after  osteotomy  is  correctly 
performed,  than  after  other  methods  of  correction, 

Wolff,  of  Berlin,  uses  silicate  bandages  as  retention  appliances  and 
the  patients  walk  about  wearing  this  form  of  support  under  the 
shoe  for  months. 

Other  varieties  are  illustrated  here. 

The  corrected  foot  tends  to  relapse  in  two  directions — inversion 
and  elevation  of  the  heel.  If  this  is  unchecked  and  walking  is 
done  in  improper  attitudes,  hurtful  pressure  and  strain  fall  upon 
the  bones  and  ligaments  of  the  foot,  and  relapse  takes  place.  This 
should  not  occur,  if  proper  retention  and  walking  with  a  proper 
attitude  of  the  foot  is  cared  for. 
32 


498 


ORTHOPEDIC  SURGERY. 


To  completely  prevent  inversion,  it  is  necessary  to  carry  the  up- 
right of  an  appliance    above  the  knee   and  secure  it  around  the 


Fig.  491. — Walking  Appliance 
with  Pelvic  Band  and   Perineal 

Straps. 


Fig.  492. — Retentive  Shoe 
with  Thigh  Attachment. 


Fig.  493. — Ankle  Support  Fre- 
quently Used  as  a  Retention  Ap- 
pliance, but  not  Efficient. 


waist.      Perineal  straps  to  the  waist-band  may  be  needed  to  pre- 
vent twisting;    but  ordinarily  in  a  completely  corrected  foot  this  is 


Fig.  494. — Retention  Shoe  without 
Thigh  Attachment.    . 


Fig.  495.  Fig.  496. 

Figs.  495  and  496. — Retention  Appliances. 


not  the  case.  Walking  appliances  not  extending  above  the  knee 
are,  as  a  rule,  not  reliable,  if  there  is  a  tendency  toward  inversion  of 
the  foot. 


CLU /!-/■()( )T. 


499 


As  these  appliances  are  to  be  worn  a  lon^^  time,  they  should  be 
light,  readily  adjusted  by  the  nurse,  not  unsightly,  and  in  no  way 
limiting  locomotion,  walking,  or  running.  The  best  are  worn  with- 
in the  shoe. 

A  form  of  appliance  to  prevent  inversion  of  the  foot  has  been 
used,  which  is  illustrated  in  the  accompanying  cut.  A  steel  rod  is 
secured  to  the  inner  side  of  the  toes  of  the  boot,  and  is  made  to 
allow  motion   in  all   directions;    at  the  heel  a  shorter  chain  is  also 


Fig.  497.— Doyle's  Appliance  for  Eversion  of  Feet; 
Spiral  Wire  Spring. 


Fig.  498. — Walking  Appliance  for  Eversion 
of  Foot. 


secured.  This  method  is  only  useful  as  a  temporary  check,  and 
cannot  be  worn  generally. 

The  well-known  Taylor  varus  appliance,  already  mentioned, 
meets  excellently  the  requirements  of  a  walking-appliance.  It  can 
be  made  thoroughly  efificient ;  it  is  light  and  not  cumbersome;  it 
does  not  require  special  skill  in  daily  application ;  it  does  not  in 
any  way  interfere  with  locomotion,  and  allows  motion  of  the  foot 
in  desired  directions.  It  can  be  worn  under  the  shoe  and  is  not 
unsightly,  and  can,  therefore,  be  worn  for  years,  if  necessary. 

If  the  heel  is  inclined  to  draw  up,  it  can  be  kept  down  without 


500 


ORTHOPEDIC  SURGERY. 


pressure  on  the  dorsum  of  the  foot  by  means  of  adhesive  plaster, 
applied  to  the  leg  and  buckling  to  the  splint.  If  the  upper  part  of 
the  upright  twists  about  the  leg,  this  can  be  prevented  by  carrying 


Fig.  499.  Fig.  500. 

Figs.  499  and  500. — Severe  Club-foot  in  a  Boy  of  Six  Before  and         Fig.  501. — Same  Case;  Walking 


After  Treatment  by  Means  of  Forcible  Rectification. 


Apparatus  Applied. 


the  upright  above  the  knee,  jointing  it  above  the  knee  and  carrying 

it  around  the  waist.' 

The    above    illustrations  indicate    the    application  of   this    form 

of  retentive  appliance. 

Fig.  449  represents  a  severe 
case  of  resistant  congenital  club- 
foot. 

The  second  illustration  shows 
the  foot  after  treatment  by 
means  of  forcible  rectification, 
the  right  foot  being  over-cor- 
rected and  the  left  foot  nearly 
corrected. 

The  third  cut  shows  the  re- 
tention apparatus  as  applied  to 
both  limbs,  the  upright  below 
the  knee  is  only  on  the  inner 
side  of  the  limb,  as  it  can  be 
more  readily  worn  in  this  way 
under  a  boot;  just  below  the 
knee  it  is  crossed  in  front  of  the 

Fig.  502.- — Appliance  to  Prevent  Inversion.  .  1    •      1  ^  j.  j_        j 

leg  and  is  bent  so  as  to  extend 
up  the  leg,  at  the  knee  and  hip  a  joint  is  furnished  and  short  waist 

'  Dr.  C.  F.  Taylor,  of  New  York,  has  efficiently  used  this  appliance  as  a  correcting 
appliance.  The  writers  have  not  been  able  to  use  it  for  this  purpose  in  cases  of  congenital 
deformity,  though  in  some  cases  of  acquired  deformity  it  has  been  successful  in  this  way. 


CLun-rooT.  501 

bands  partly  encircling  the  waist  are  furnished  with  straps,  and 
when  strapped  together  prevent  inversion  of  the  feet. 

Relapses. — No  error  is  greater  than  a  common  one,  namely,  that 
tenotomy  alone  is  sufficient  to  correct  club-foot.  In  fact,  tenotomy 
is  only  the  beginning  of  a  course  of  treatment.  If  the  foot  is  recti- 
fied and  held  in  place  for  a  month,  it  is  supposed  by  some  surgeons 
that  a  cure  has  been  effected.     But  such  is  by  no  means  the  case. 

Moreover,  it  must  always  be  borne  in  mind  that  relapses  will  in- 
variably occur  unless  the  distortion  is  completely  corrected,  and  in 
fact  over-corrected.  In  club-foot  half-cures  are  no  cures,  and  little 
reliance  can  be  placed  on  the  curative  effect  of  time.  Efforts  at 
correction  should  be  continued  until  the  foot  can  be  easily  ab- 
ducted beyond  the  median  line,  and  while  slightly  abducted,  can  be 
flexed  so  that  the  dorsum  of  the  foot  shall  form  less  than  a  right 
angle  with  the  leg,  the  sole  of  the  foot  being  flat,  there  being  no 
twist  in  the  front  of  the  foot.  After  this  the  correction  appliance 
is  to  be  changed  for  a  retention  appliance. 

Relapses  occur  in  a  certain  number  of  cases  simply  from  the 
carelessness  of  the  parents,  who  are  not  aware  of  the  necessity  of 
retaining  the  corrected  foot  in  the  proper  position  for  a  long  time. 
The  foot  of  a  healthy  infant  in  arms  is  often  held  in  an  equinus 
position,  which  is  often  overlooked  by  the  parent. 

In  cases  where  the  counteracting  muscles  are  congenitally  weaker 
than  they  should  be,  there  is,  of  course,  danger  that  the  gastrocne- 
mius muscles  may  become  shortened  by  adaptive  shortening,  even 
if  previously  of  sufficient  length,  as  happens  in  the  case  of  infantile 
paralysis.  Where  the  foot  is  large  and  the  child  able  to  walk,  the 
act  of  walking  aids  correction  if  the  foot  is  prevented  from  twist- 
ing and  the  weight  falls  correctly  on  the  sole.  But  in  infants 
in  arms  this  correcting  influence  is  absent,  and  the  retentive  ap- 
pliance needs  to  be  carefully  watched  until  the  child  walks  and 
walks  well.     In  cases  of  relapse  a  second  tenotomy  is  advisable. 

Relapses  in  older  children  are  due  to  incomplete  correction, 
either  from  a  lack  of  thoroughness  or  from  the  existence  of  an 
unusual  amount  of  distortion  of  the  astragalus  not  suspected,  and 
demanding  osteotomy,  or  from  too  early  removal  of  the  fixation 
appliance.  It  may  be  said,  however,  that  the  larger  the  foot  the 
less  time,  after  complete  correction,  will  a  walking-appliance  be 
needed. 

In  some  instances  of  resistant  club-foot  it  is  found  impossible,  in 
correcting  the  foot,  to  completely  over-correct  the  equinus  deform- 
ity, and  to  enable  the  foot  to  be  brought  within  a  right  angle  of  the 
leg.  If  this  is  not  done,  inconvenience  is  felt  by  the  patient  in 
taking  a  long  step,  and  the  foot  is  turned  in  to  facilitate  this.     The 


502 


OR  THOPEDIC  S  URGER  V. 


smaller  the  foot,  the  greater  this  danger.  If  this  is  not  corrected, 
it  may,  in  some  instances,  seriously  interfere  with  the  perfection  of 
the  result. 

Relapses  in  infantile  club-foot  may  also  occur  from  the  neglect 
of  a  fixation  shoe.  In  children  in  arms,  the  feet  hang  according  to 
gravity,  unless  the  muscles  are  of  normal  activity.  The  muscles 
in  club-foot,  even  after  correction,  are  not  of  normal  activity;  and 
the  feet  may  relapse  and  deformity  reappear,  as  in  cases  of  paraly- 
tic  club-foot.  This  may  also  result  if  the  children  do  not  walk 
correctly  when  they  attempt  to  walk. 

It  should  also  be  borne  in  mind  that  a  distortion  in  the  neck  of 
the  astragalus  exists,  even  in  infantile  club-foot,  and  that  the  feet 


Fig.  503.— Double  Congenital  Equino- Varus. 


are  not  permanently  corrected  until  the  alteration  of  the  facets 
into  a  normal  position  has  taken  place.  This  is  independent  of 
bringing  the  foot  into  a  normal  position,  and  demands  fixation  in  a 
normal  position  for  some  time.  In  some  cases  this  is  more  needed 
than  in  others,  probably  because  the  alterations  of  the  facets  of  the 
astragalus  are  in  some  instances  slight. 

Imperfect  Results. — The  obstacles  which  prevent  perfection  in 
result  are  as  follows:  Imperfectly  divided  tendons;  imperfectly 
divided  ligaments  and  plantar  fascia;  imperfectly  stretched  liga- 
ments; incorrect  relation  between  the  scaphoid  and  anterior  facet 
of  the  astragalus,  due  either  to  anatomical  alteration,  of  shape  of 
the  astragalus  or  to  imperfect  division  or  stretching  of  the  liga- 


CLirn-FooT. 


503 


ments  which  bind  these  bones  together,  in  the  correction  rjf  the  de- 
formity. 

Too  great  over-correction  of  the  deffjrmity,  and  tlie  develfjpment 
of  a  splay-foot  have  sometimes  resulted  from  over-zealous  treat- 
ment. The  danger  is,  however,  not  great;  and  instances  arc  rare, 
and  are  to  be  overcome  by  the  treatment  for  a  valgus  foot. 

Inversion  of  the  foot,  after  cure  of  the  club-foot,  may  in  a  few 
instances  be  observed  from  imperfect  strength  of  the  outward  rota- 
tory muscles  at  the  hip.  This,  however,  causes  but  little  disfigure- 
ment, the  inversion  usually  being  slight,  and  corrects  itself  by  the 
normal  development  of  the  muscles.     A  marked  toeing-in  of  the 


Fig.  505.- 


-Side  View  at  Age  of  Twelve.    Left  foot  forward 
showing  amount  of  motion  at  ankle. 


Fig.  504. — Condition  of   Feet 

at  the  Age  of  Twelve. 

Front  View. 


Fig.  506. — Right  Foot  Forward. 


foot  in  running  persists  a  long  time  in  some  instances  where  the 
foot  is  entirely  corrected  and  the  walking  is  normal.  It  disappears 
with  the  increase  of  muscular  strength. 

A  relaxed  state  of  the  knee-joint  causing  inversion  of  the  tibia  is 
not  uncommon  in  infantile  club-foot;  it  usually  corrects  itself  in 
the  development  of  the  child  after  correction  of  the  foot.  In  rare 
instances,  however,  it  may  persist,  requiring  the  longer  use  of  a 
walking  appliance. 

There  appears  to  be  no  greater  liability  to  relapse  after  complete 
correction  by  mechanical  means  than  when  tenotomy  is  employed. 

The  accompanying  pictures  (Figs.  504,  505,  506)  are  taken  from  the 
photograph  of  the  feet  of  a  child  of  twelve  years  born  with  talipes 
■?quino-varus  of  a  severe  type.    No  cast  of  the  feet  at  the  time  of  in- 


504  ORTHOPEDIC  SURGERY. 

fancy  was  taken,  but  the  feet  resembled  those  in  the  preceding  cut 
(Fig.  503).  Treatment  was  begun  at  the  age  of  three  months,  and  was 
entirely  mechanical,  and  several  months  were  needed  for  correction, 
bandages  and  traction  being  chiefly  employed.  A  retention  appli- 
ance was  worn  for  a  year  and  no  subsequent  treatment  was  needed. 

Treatment  of  the  Muscles.— The  muscles  retarded  in  club-feet 
by  disuse,  need  development  before  a  complete  cure  is  effected. 
Ordinarily  the  muscles  develop  of  themselves  after  complete  cor- 
rection, if  the  limbs  are  actively  used.  In  some  cases  the  develop- 
ment is  slow  and  massage  and  electricity  are  advisable. 

Generalization  as  to  Treatment. — The  literature  of  the  treatment 
of  club-foot  is  too  often  that  of  unvarying  success.  It  is  some- 
times as  brilliant  as  an  advertising  sheet,  and  yet  in  practice  there 
is  no  lack  of  half-cured  or  relapsed  cases — sufificient  evidence  that 
rriethods  of  cure  are  not  universally  understood. 

The  following  different  questions  in  regard  to  treatment  at  pres- 
ent are  differently  answered  by  different  surgeons : 

1.  In  what  cases  is  it  advisable  to  correct  and  treat  by  mechani- 
cal means  alone,  without  the  help  of  any  operative  interference, 
even  tenotomy  ? 

2.  When  is  tenotomy  advisable  ? 

3.  Can  severe  cases  be  entirely  corrected  and  permanently  cured 
without  tarsal  resection  or  osteotomy  ? 

4.  Is  tarsal  resection  or  osteotomy  a  justifiable  operation  ? 
The  writers  have  been  led  to  believe : 

1.  That  the  cases  of  infantile  club-foot  can,  as  a  rule,  be  thor- 
oughly and  efficiently  treated  without  tenotomy  by  mechanical 
correction  and  mechanical  retention  alone.  Tenotomy,  however, 
is  an  aid  even  in  infantile  cases. 

2.  That  in  older  cases  tenotomy  aids  the  correction,  and  is  not 
injurious  in  the  permanent  result. 

3.  That,  as  a  rule,  resistant  cases  of  the  severest  type  can  be 
corrected  without  tarsal  osteotomy,  by  forcible  rectification. 

4.  That  in  exceptional  cases  of  resistant  club-foot,  tarsal  osteot- 
omy may  be  needed  for  perfect  rectification,  and  is  not  only  justi- 
fied, but  may  be  indicated  in  exceptional  instances. 

In  regard  to  the  choice  of  appliances  and  methods,  much  must 
be  left  to  the  training  of  the  surgeon  and  to  the  methods  in  which 
he  is  most  proficient. 

The  writers  are  inclined,  from  their  own  experience,  to  make  the 
following  recommendations:  In  infantile  cases  the  thorough  use 
for  a  few  weeks  of  a  corrective  appliance  (the  modified  Beely  ap- 
paratus by  preference)  is  advisable  without  tenotomy,  and  treatment 
should  be  begun  as  early  as  practicable. 


CL  UJl-1'00  T. 


;o: 


If  correction  is  incomplete  after  a  trial  with  mechanical  treat- 
ment for  several  weeks  or  months,  the  employment  of  tenotomy, 
with  immediate  fixation  in  an  over-corrected  position  is  desirable, 


Fig.  507.— Congenital  Club-foot. 


Fig.  508. — The  Same  Case;  Result  of  Treatmeni. 


with  subsequent  use  of  a  retention  shoe  until  the  child  walks  per- 
fectly. 

In  older  children  in  arms,  mechanical  correction  may  be  either 

by  the  use  of  the  Taylor  shoe  or  the 
employment  of   corrective    appliances, 
such  as  the  Shaffer  shoes. 
^^y<^^^^~^       \V^  11  The  after-use  of  the  retention  shoe 

is  necessary,  that  of  Taylor  being  the 
simplest  and  most  eflficient  walking 
appliance. 


Fig.  509— The  Same  Case,  withAppliance  for  Correction. 


Fig.  510. — Sole  of  Corrected  Foot. 


Of  the  treatment  of  club-foot  in  children  who  are  able  to  walk, 
very  much  the  same  can  be  said  as  of  the  treatment  in  infants,  ex- 
cept that  mechanical  correction  is  more  tedious  and  therefore  ope- 
rative means  are  to  be  preferred. 


5o6 


ORTHOPEDIC  SURGERY. 


In  older  children,  of  the  age  of  five  years  or  upward,  not  only  the 
use  of  the  tenotome,  but  the  employment  of  considerable  correct- 
ing force,  as  a  rule,  is  required.  Mechanical  correction  without  the 
aid  of  operation,  demands  much  patience  on  the  part  of  the  sur- 
geon and  time  on  the  part  of  the  patient,  which  can  be  avoided  by 
the  use  of  the  tenotome  and  a  forcible  correction. 

A  choice  between  forcible  rectification  and  osteotom.y  depends, 
upon  the  amount  of  bone  change,  upon  the  age  of  the  patient,  and 
also  upon  the  amount  of  time  the  patient  can  devote  to  treatment. 

The  writers,  basing  their  experience  on  a  large  number  of  forci- 
ble rectifications,  would  agree  entirely  with  Wolff,  of  Berlin,  that 
by  forcible  rectification  the  severest  forms  of  club-feet  can  be  cor- 


i"iG.  511.  Fig.  512. 

Figs.  511  and  522. — Severe  Club-foot  Before  and  After  Treatment. 


rected.'  The  preceding  cuts  (Figs.  507-510)  taken  from  photo- 
graphs, illustrate  a  case  of  congenital  club-foot  in  a  girl  of  eighteen. 
The  deformity  was  originally  double,  but  one  foot  had  been  cor- 
rected in  childhood  at  her  home  (Germany)  by  operative  measures. 
The  other  foot  had  relapsed. 

Correction  was  done  by  means  of  forcible  rectification,  two  sit- 
tings being  necessary.  The  condition  of  the  feet  at  the  end  of  four 
months  is  illustrated,  the  retentive  appliance,  such  as  is  seen  in  the 
accompanying  cut,  being  worn  for  six  months.  The  cure  remained 
permanent,  the  patient  having  been  heard  from  six  years  after 
treatment. 

Similar  cases  of  congenital  deformity  in  a  girl  of  eleven  and  a  boy 

'  Analysis  of  Results  in  loo  cases  of  Club-Foot :  E.  H.  Bradford  ;  Trans.  American 
Orthopedic  Association,  vol.  i.,  1889. 


CLUIi-jyOOT. 


507 


of  ten  are  illustrated  in  the  preceding  cuts,  taken  from  photoj^raphs 
(Figs.  511,  512).    Forcible  correction  was  made,  and  a  cure  effected. 

Tarsal  resection  should  be  avoided  if  possible,  as  the  method  in- 
volves mutilation  of  the  foot,  but  it  is  sometimes  necessary  as  more 
speedy. 

The  treatment  of  congenital  club-foot  in  brief  consists  of  com- 
plete correction  and  of  efficient  retention. 

Treatment  should  be  begun  as  early  in  infancy  as  is  practicable. 

Correction  in  infancy  and  early  childhood  can  be  entirely  me- 
•chanical,  and  the  amount  of  time  gained  by  tenotomy  is  not  great. 

Tenotomy  saves  time  in  older  children.     In  congenital  cases  ten- 


FiG.  513.  Fig.  514. 

Figs.  513  and  514. — Severe  Club-foot  Before  and  After  Treatment. 


otomy  should  be  followed  by  complete  correction  and  retention  in 
a  corrected  position. 

In  walking  children,  the  retentive  appliance  should  not  interfere 
with  locomotion,  should  be  readily  applied,  not  unsightly,  and  be 
worn  as  long  as  there  is  a  tendency  of  the  foot  to  bear  the  weight 
unequally. 

In  resistant  cases  much  force  should  be  applied  for  correction; 
correction  should  be  complete,  followed  by  fixation ;  and  after 
correction  a  retentive  appliance. 

Tarsal  resection  should  be  reserved  only  for  the  severest  cases, 
where  correction  by  force  has  only  partially  succeeded.  These 
cases  will  be  found  to  be  very  few. 

Acquired  Club-Foot — Paralytic   Cases  of  the  Eq?(i}w-  Variis. — The 


5oS  ORTHOPEDIC  SURGERY. 

most  common  form  of  acquired  club-foot  is  that  following  infantile 
paralysis  which  is  described  in  another  chapter. 

The  prognosis  of  paralytic  club-foot  is  necessarily  more  unfavor- 
able than  the  congenital  form,  although  the  distortion  is  more 
readily  corrected,  yet  it  is  impossible  to  restore  the  affected  mus- 
cles to  a  normal  condition,  and  the  prolonged  use  of  some  form  of 
appliance  is  necessary. 

In  some  instances,  however,  after  thorough  correction  and  reten- 
tion for  a  while  in  a  corrected  position,  if  the  foot  is  of  sufficient 
size  relapse  does  not  take  place,  or  only  in  a  partial  degree,  and  a 
useful  and  but  slightly  distorted  foot  remains. 

The  treatment  of  paralytic  club-foot  is  to  be  conducted  on  the 
same  principles  as  the  congenital  type. 

Correction  is,  however,  much  less  difficult,  as  osseous  changes 
are  only  present  in  the  old  severe  and  neglected  cases. 

Operative  interference  is  often  unnecessary  if  thorough  mechan- 
ical treatment  is  applied  and  time  is  not  an  object. 

But  tenotomy  of  the  contracted  and  healthy  muscles  can  be 
done  as  in  congenital  cases,  though  over-correction  after  tenotomy 
is  to  be  avoided.  Immediate  correction  and  fixation  in  a  cor- 
rected position  is  to  be  used  after  tenotomy  as  in  the  congenital 
form. 

The  walking  appliance  to  be  used  in  paralytic  cases  resembles 
what  has  been  described  in  consrenital  cases. 


CHAPTER   XIV. 
CONGENITAL   DISLOCATIONS. 

Congenital  Dislocations. — Occurrence,— Congenital  Dislocation  cri  the  Hip. — Fre- 
quency and  Occurrence. — Etiology. — Pathology. — Symptoms. — Diagnosis. — 
Differential  Diagnosis. — Prognosis. — Treatment. — Congenital  Dislocations  of 
other  Joints  than  the  Hip. 

Occurrence. 

Congenital  dislocations,  with  the  exception  of  dislocations  of 
the  hip,  occur  so  rarely  that  they  are  of  interest  chiefly  as  surgical 
curiosities.  The  very  great  preponderance  of  hip  dislocations 
among  these  has  never  been  satisfactorily  explained,  and  so  few 
cases  of  congenital  dislocations  of  other  joints  have  been  reported, 
that  the  etiology  of  the  affection  is  obscure,  except  for  the  light 
afforded  by  the  study  and  analysis  of  the  hip  dislocations.  There 
is  one  point  of  difference  in  the  occurrence  of  congenital  disloca- 
tion of  the  hip  and  of  the  other  joints.  Dislocations  of  the  hip 
occur  most  often  in  otherwise  healthy  and  normally  formed  chil- 
dren, while  dislocations  of  the  other  joints  are  commonly  associ- 
ated with  other  malformations,  such  as  acrania,  anencephalia,  spina 
bifida  and  the  like. 

While  90  cases  of  congenital  hip  dislocation  were  seen  at  Lan- 
genbeck's  Policlinic,  there  were  5  congenital  dislocations  of  the 
shoulder,  2  of  the  head  of  the  radius  and  one  of  the  knee.  Hibon 
collected  1 1  cases  of  congenital  dislocation  of  the  knee. 

A  condition  of  congenital  laxity  of  the  ligaments  is  occasionally 
seen  so  closely  allied  to  dislocation  that  it  should  be  mentioned 
here,  as  in  certain  cases  of  laxity  of  the  temporo-maxillar}-  joint. 
Portal '  relates  of  the  Abbe  de  Saint  Bonnet,  that  he  could  dis- 
locate his  hip-joint  at  will  and  the  head  of  the  femur  could  be  felt 
against  the  ilium,  and  Humbert  and  Jacquin  relate  a  still  more  re- 
markable case  where  they  speak  of  a  surgeon  whom  the}-  knew, 
who  could  not  only  completely  dislocate  his  hip-joint,  but  return, 
the  head  of  the  femur  to  its  place  without  touching  or  handling 
the  leg.     This  condition,  however,  is  due  not  only  to  a  laxity  of 

^Portal:  Anat.  Med.,  i.,  470. 


5IO 


ORTHOPEDIC  SURGERY. 


ligaments,  but  especially  to  a  peculiar  condition  of  the  muscles 
by  which  certain  ones  can  be  relaxed  to  an  unusual  extent,  so 
that  contraction  of  certain  other  muscles  meets  with  no  resistance. 
It  will  be  best  to  consider  first  congenital  dislocations  of  the 
hip  and  then  to  speak  more  briefly  of  dislocations  of  the  other 
joints. 

Congenital  dislocation  of  the  hip  is  not  a  common  affection,  nor  is 
it  one  of  very  great  rarity.  Among  3,100  cases  of  surgical  dis- 
ease in  children,  applying  at  the  out-patient  department  of  the 
Children's  Hospital,  there  were  24  cases  of  congenital  dislocation 
of  one  or  both  hips.  Chaussier,'  in  23,293  infants  born  at  the 
Maternite,  found  only  i  case  of  congenital  luxation.  But  it  is 
probable  that  it  occurs  in  reality  much  oftener  than  it  is  recog- 
nized clinically.  Parise""  dissected  the  hip  joints  of  all  children 
dying  while  he  was  interne  at  the  Hopital  des  Infants  Trouves,  and 
in  332  he  found  congenital  dislocation  of  one  or  both  hips  in  3.^ 

The  distribution  of  the  affection  between  the  sexes  and  in  one 
or  both  joints  can  be  seen  from  the  following  tabulation  of  col- 
lected cases. 

Number.  Boys.  Girls.  Right^^Left.  Double. 

Drachmann 77  10  67  24  24  29 

Pravaz 107  il  96  27  29  51 

Kronlein .  . . ; 90  14  76  32  22  31 

N.  Y.  Orth.  Hosp.  and  Disp 25  2-23  5  10  5 

Boston  Children's  Hospital 24  o  24  7  11  6 

Prahl 18  3  15  o  o  o 

341  40     301  95         96  122 

The  affection  is  much  more  common  in  girls  than  in  boys,  301  of 
these  341  cases  (88  per  cent)  having  been  observed  in  females.  No 
etiological  reason  worth  repeating  has  ever  been  advanced  to  ac- 
count for  this  preponderance  in  girls  except  the  assertion  of  Du- 
puytren,  that  females  are  more  liable  to  malformation  than  males. 

Etiology. 

The  affection  has  been  known  for  so  long  a  time  that  practically 
numberless  theories  have  been  advanced  to  account  for  the  de- 
formity. Kronlein's  classification  of  these  is  the  best  and  briefest. 
It  is  given  here  merely  in  outline. 

I.  The  so-called  dislocation  is  traumatic  and  caused, 
[a)  By  external  violence,  as  by  a  fall  in  pregnancy  or  by  violent 
muscular  action  on  the  part  of  the  foetus. 

'  Chaussier,  quoted  by  Kronlein  :  Deutsch.  Chir. ,  Lief.  26,  p.  83. 

^  Parise :  Bull,  de  la  Soc.  de  Chir.,  1866,  vol.  vii. ,  p.  331. 

3  Prahl:  Liaug.  Diss.  Breslau.     Abst.  Cent.  f.  Chir.,  1881,  p.  57. 


CONGI'INI'JAJ.   J)JSJA)CArJi)j\'S.  311 

{U)  By  injury  during  birth,  especially  in  breech  presentations, 
the  percentage  of  which  is  abnormally  large  in  cases  of  congenital 
dislocation.  Adams,  for  instance,  found  7  breech  labors  in  45  cases. 
Capuron,  Chelius,  and  D'Outrepont  are  the  chief  ones  who  have 
called  attention  to  this  with  Brodhurst,'  who  makes  it  the  only 
cause. 

II.  The  congenital  luxation  is  spontaneous,  {a)  and  is  due  to 
softness  and  laxity  of  the  joint  ligaments  (Sedillot  and  Stromeyer); 
(/?)  or  to  a  fcetal  hydrarthrus  (Parise),  or  even  joint  fungus  with 
effusion,  or  caries  (Verncuil,  Broca,  Morel-Lavallee,  Albers). 

III.  The  dislocation  is  due  to  the  peculiar  position  of  the  lower 
extremities  of  the  foetus  in  utero. 

{a)  Where  strong  flexion  of  the  thigh  and  weak  hip  ligaments 
coexist  (Dupuytren);  (/;)  when,  on  account  of  a  small  amount  of 
amniotic  fluid,  the  pressure  of  the  abdominal  walls  causes  an  undue 
amount  of  adduction  of  the  thighs  (Roser). 

IV.  The  dislocation  is  due  to  a  primary  m.uscular  contraction, 
which  is  to  be  regarded  as  the  expression  of  some  central  nervous 
lesion  (Guerin,  Chaussier,  Melicher,  Mercer,  Adam,  Carnochan). 

V.  It  is  due  to  paralysis  of  the  peritrochanteric  muscles  (Ver- 
neuil,  Reches,  Kirmisson,  Dalby). 

VI.  It  is  due  in  most  cas(is  to  arrested  development.  This 
theory  rests  on  a  solid  scientific  basis,  and,  it  will  be  seen,  is  to  be 
accepted  as  the  satisfactory  one  in  most  cases.  Originally  ad- 
vanced by  Paletta,  it  has  been  taken  up  by  Schreger,  Dupuytren, 
Von  Ammon,  Breschet  and  others. 

This  theory,  known  most  commonly  as  Ammon's,  advanced  in 
1842,  has  of  late  years  received  a  confirmation  in  the  researches  of 
Dollinger-  and  Grawitz.^  The  former  considered  the  cause  to  lie 
in  a  premature  ossification  of  the  Y-cartilage  at  the  bottom  of  the 
acetabulum,  while  Grawitz,  examining  twelve  specimens  of  congen- 
ital hip  dislocation  taken  from  seven  new-born  children,  concluded 
that  oftener  the  dif^culty  lay  in  a  retarded  growth  of  the  Y-carti- 
lage and  that  its  arrest  of  development  was  the  cause  of  its  failing 
to  carry  on  the  growth  of  the  three  segments  forming  the  acetab- 
ulum, and  the  experiments  of  Grawitz  Avere  numerous  and  careful 
enough  to  establish  his  point. 

There  is  another  and  somewhat  simpler  view  of  the  cause  of  the 
malformation  of  the  acetabulum,  and  this  view  attributes  it  to  the 
absence  of  a  rim  to  the  acetabulum.  Mr.  Lockwood  showed  to 
the  Pathological  Society,  two  foetuses  born  at  full  term,  illustrating 

'  Brit.  ]\red.  Journal,  Nov.  7th,  18SS. 

-  Dolling-er  :  Arch    f.  klin.  Chir. ,  1S77,  Bd.  xx. 

3  Grawitz:    Virch.  Arch.,  1S78,  74,  i. 


512 


ORTHOPEDIC  SURGERY. 


this  condition,  but  where  dislocation  of  the  head  of  the  femur  had 
not  taken  place.' 

Any  arrest  of  the  development  and  growth  of  the  acetabulum 
would  result  in  a  shallow  and  imperfect  acetabulum,  and  displace- 
ment of  the  femur  would  be  favored.  And  thus  the  present  ten- 
dency is  to"  regard  congenital  dislocation  in  most  cases  as  a  con- 
genital deformity  resulting  from  retarded  development  rather  than 
as  the  result  of  violence  at  birth,  in  short  to  bring  it  into  line  with 
other  deformities  as  the  persistence  of  a  foetal  condition.  And  it 
is  not  uncommon,  as  has  been  seen,  to  find  associated  with  con- 
genital hip  dislocation,  other  serious  congenital  malformations  if 
one  considers  young  children.  Grawitz's  cases  all  had  other  mal- 
formations, serious  enough  to  be  fatal,  and  the  same  fact  has  been 
noted  by  Cruveilhier  and  Voss. 

There  is,  undoubtedly,  a  tendency  to  heredity  in  congenital  hip 
dislocation.  Dupuytren^  relates  the  case  of  three  families  where 
the  affection  was  present  in  several  members,  and  cases  are  related 
by  Bouvier,3  Verneuil,*  Stadfeldt,  Caswell,  and  Volkmann.^ 

Pathology. 

By  far  the  most  common  form  of  the  dislocation  is  upward  on  to 
the  dorsum  of  the  ilium.  Cases  have  been  reported  where  the 
head  of  the  femur  was  dislocated  on  to  the  pubis  and  into  the 
obturator  foramen ;  they  are,  however,  the  greatest  of  rarities.* 

The  head  of  the  femur  may  be  normal  or  it  may  be  entirely  ab- 
sent, and  as  a  rule,  there  is  some  abnormality  present,  and  the  neck 
of  the  femur  is  shorter  and  more  horizontal  than  usual.  The  liga- 
mentum  teres  may  be  wanting,  or  very  much  attenuated,  while  in 
other  instances  it  is  so  much  thickened  and  stretched,  that  it  has 
evidently  helped  to  support  the  body  weight.'  It  may  also  be 
merged  in  the  joint  capsule.® 

The  capsule  is  usually  entire,  but  the  wearing  upon  it  of  the 
head  of  the  femur  may  cause  it  to  atrophy  in  that  location.  It  is 
thickened  and  stretched  and  may  be  constricted  at  its  centre  into 

^  Path.  Soc.  Trans.,  vol.  xxxviii. ,  308. 

^  Dupuytren :   "  Le9ons  orales  de  Clin.  Chir. ,"  Paris,  1832,  tome  iii. ,  Art.  viii. 
3  Bouvier:  "  Le9.  Clin,  sur  les  mal.  chron.  de  I'app.  locomoteur. " 
'*  Verneuil:    Gaz.  des  Hop.,  1866,  68,  76. 
5  Volkmann:   "  Krankheiten  der  Bewegungsorgane. " 
*  Stimson:    "  Dislocations,"  Phila.,  1888,  p.  103. 

7  Holmes-Coote,    Adams:     "Todd's   Encyc,"   vol.   ii.;    Breschet:    L.    M.    and    S. 
Journal,  1835;  Journ.  Edin.  Phys.  Soc,  1855. 

^  Bouvier:   Arch.  Gen.  de  Med.,  Paris,  xiv.,  p.  439. 


CONGENITylL    J)/S/JJCAV7UNS.  513 

an  hour-glass  form.'  This  hypcrtropliy  is  the  result  of  its  new 
function  in  supporting  the  body  weight,  for  the  body  is  suspended 
from  the  femurs  by  the  capsules,  as  Volkmann  lias  jjointed  f;ut, 
just  as  an  old  fashioned  stage  coach  was  hung  on  its  leather  springs. 

The  acetabulum  has  been  found  abnormal  in  all  recorded  cases, 
but  never  entirely  absent.  It  is  cither  undeveloped  and  smaller 
and  shallower  than  normal  or  it  may  appear  as  a  flattened  oval. 
The  cartilaginous  rim  may  be  entirely  wanting  and  there  is  gener- 
ally hypertrophy  of  the  acetabular  fat.  The  muscles  around  the 
hip-joint  are  irregular  and  undeveloped. 

On  account  of  the  new  position  of  the  head  of  the  femur,  above 
and  behind  the  true  site  of  the  acetabulum,  often  a  growth  of  bone 


Fig.  515. — The  Preparation  of  a  Specimen  of  Congenital  Dislocation  of  the  Hip.     Dupuytren  i^Iuseum. 

will  be  found  forming  an  upper  rim  to  the  nev/  socket,  to  which  the 
upper  edge  of  the  capsule  is  attached,  and  often  bone  is  deposited 
on  the  inner  surface  of  the  pelvis  under  the  new  acetabulum.  The 
pelvis  is  partly  suspended  by  the  capsular  ligaments,  partly  sup- 
ported by  the  formation  of  a  new  acetabulum  and  the  peritrochan- 
teric  muscles,  and  even  the  psoas  and  iliacus  help  in  the  suspension. 
If  the  point  of  suspension  is  directly  over  the  proper  place  for  the 
acetabulum,  the  patient's  pelvis  is  hung  in  a  comparatively  normal 
plane,  but  if  much  behind  it  the  pelvis  is  tilted  and  severe  lordosis 
results,  the  later  being  the  more  common  condition. 

'  Holmes-Coote:    Lancet,   i860.     N.  Y.  Journ.  of  Med.,  184S,   Carnochan:    Berend: 
B.  Med.  Journ.,  1861;  Canton:  London,  Med.  Gaz.,  xli.;  Birnbaum:  Wien.  Med.  Presse, 
1859;  Bouvier:    Bull,  de  I'Acad.  de  Med.,  1S3  &;  9. 
2>2> 


SH 


ORTHOPEDIC  SURGERY. 


Hung  in  this  way,  the  pelvis  develops  abnormally,  the  crests  of 
the  ilia  approach  each  other,  the  tuberosities  of  the  ischia  become 
further  apart,  the  whole  centre  of  the  bone  is  carried  upward  and 
backward,  and  the  lateral  surfaces  thus  tend  to  become  vertical. 
The  new  acetabulum  formed  above  the  old  one  is  often  deep 
enough  to  afford  good  support.  All  the  mechanical  treatment 
must  necessarily  be  directed  to  forming  such  a  cavity.  The  pres- 
sure and  friction  of  the  head  of  the  femur  in  its  new  place,  causes 
absorption  of  the  periosteum  and  joint  capsule  in  that  place,  and 
the  capsule  finds  a  new  attachment  in  the  osteophytes  thrown  out 
to  form  an  upper  rim  to  the  cavity  in  favorable  cases. 

Symptoms. 

The  deformity  usually  attracts  no  attention  until  the  child  learns 
to  walk  at  the  age  of  two  or  even  three  years.  Then  it  is  noticed 
to  stand  ordinarily  with  its  back  very  much  arched  and  to  waddle 
most  markedly  when  walking  is  well  begun.  This  waddle  is  char- 
acteristic and  very  marked.  When  the  dislocation  is  only  unilat- 
eral, the  waddle  becomes  an  exaggerated  limp;  in  stepping  on  that 
leg,  the  child  suddenly  lurches  violently  to  the  affected  side,  and 
the  leg  seems  to  have  grown  suddenly  shorter,  the  child  recovers 
himself  at  once  and  goes  on  with  this  sudden  giving  way  whenever 
the  affected  leg  is  stepped  upon.  In  double  dislocation,  in  young 
children,  the  prominence  of  the  trochanters  is  not  marked  enough 
to  attract  attention;  in  older  persons,  however,  the  prominence  of 
the  trochanters  and  buttocks  is  most  noticeable.  There  is  no  com- 
plaint of  pain  as  a  rule,  although  people  with  such  deformities  are 
particularly  subject  to  sprains  and  wrenches  of  their  imperfect 
joints.  They  tire  more  easily  than  other  children,  although  often 
their  endurance  is  wonderful  when  one  considers  how  serious  is 
their  mechanical  disability. 

Diagnosis. 

The  diagnosis  rests  chiefly  on  one  point,  the  position  of  the  tro- 
chanters above  Nelaton's  line,  which  is  drawn  from  the  anterior 
superior  spine  of  the  ilium  to  the  tuberosity  of  the  ischium.  In 
small  children  it  is  often  a  difficult  point  to  determine  whether  the 
trochanter  is  on  the  line  or  very  slightly  above  it.  The  displace- 
ment of  the  trochanter  upward  varies  from  half  an  inch  to  one  or 
two  inches,  according  to  the  severity  of  the  case. 

As  the  child  lies  on  its  back,  the  perineum  is  noticed  to  be  unu- 
sually broad,  the  legs  will  perhaps  be  everted,  perhaps  in  normal 


CONGF-NITAf.    D/SLOCIT/ONS.  515 

position,  and  on  manipulating  thcin  tlicy  will  be  found  to  be  unu- 
sually movable,  especially  in  the  direction  of  eversion.  A  click 
more  or  less  marked  will  ortlinarily  l)e  felt  as  the  hearl  of  the 
bone  gildes  over  a  band  of  fascia  or  the  rudimentary  acetabulum, 
but  a  similar  click  is  sometimes  felt  in  children  with  normal  hip- 
joints. 

On  pulling  the  leg  with  gentle  force,  the  trochanter  will  be  felt 


Fig.  516. — Side  View  of  a  Case  of  Congenital 
Dislocation  of  Both  Hips. 


Fig.  517. — Posterior  View  of  a  Case  of  Congenital 
Dislocation  of  Both  Hips. 


to  come  down,  if  the  other  hand  is  placed  upon  it,  and  to  slip  back 
when  the  leg  is  released,  and  a  measurement  will  show  that  the 
leg  has  actually  been  lengthened  temporarily.  This  movement  is 
most  marked  when  the  thigh  is  flexed  and  traction  is  made  at  a 
right  angle  to  the  axis  of  the  body. 

The  muscles  are  in  good  condition  and  the  children  ordinarily 
very  healthy  ones.  In  unilateral  dislocation,  the  leg  of  the  effected 
side  is  slightly  smaller  than  the  other. 


ri6  ORTHOPEDIC  SURGERY. 

The  diagnosis  must  not  b&  made  on  the  simple  shortening  of  one 
leo-.  That  is  so  common  an  occurrence  in  children  otherwise  nor- 
mal, that  it  is  of  slight  importance  unless  there  is  the  additional 
sien  of  a  trochanter  above  Nekton's  line. 


Fig.  518. — Congenital  Dislocation  of  the  Hip,  Showing  Outline  of  the  Displaced  Trochanters  and  the 
,  Arching  of  the  Back  in  a  case  of  Moderate  Severity. 

In  larger  children  and  adults,  the  conformation  and  outline  of 
the  hips  is  so  distinctive  that  the  diagnosis  may  be  made  almost  at 
a  glance,  but  in  young  children  this  is  not  the  case.  The  contour 
of  the  buttocks  and  hips,  as  shown  in  the  figure  of  a  girl  approach- 
ing puberty,  is  perfectly  distinctive. 


CONGENITAL   DISLOCATIONS.  517 

In  small  children  the  diagnosis  may  be  decidedly  difficult.  The 
best  idea  of  it  can  be  obtained  from  the  abnormal  mobility  of  the 
hip-joints  with  the  fact  that  they  yield  on  tractitm.  A  dislocated 
leg  can  generally  be  flexed  and  adducted  until  it  lies  along  the 
child's  abdomen. 

There  are,  probably,  cases  of  partial  luxation  without  distinctive 
signs  enough  to  warrant  a  diagnosis.  One  sees  children  sometimes 
who  have  a  tendency  to  waddle  and  whose  joints  are  more  than 
ordinarily  lax,  but  where  the  trochanter  is  in  place  and  the  joint 
yields  but  little  to  traction. 

Differential  Diagnosis. 

There  are  two  affections  with  which  congenital  dislocation  of  the 
hip  may  be  confounded — bowlegs  and  infantile  paralysis.  A  child 
with  severe  bowlegs  "waddles"  in  walking  almost  as  much  as  a 
child  with  double  dislocation,  and  on  account  of  the  rotation  of 
the  pelvis  stands  with  some  apparent  lordosis.  But  it  is  generally 
easy  to  establish  the  position  of  the  trochanters  and  so  to  make  the 
diagnosis.  It  should,  however,  be  borne  in  mind  that  the  presence 
of  bowed  tibias  does  not  exclude  dislocation  of  the  hips,  as  both 
affections  may  be  present. 

The  gait  of  a  child  with  infantile  paralysis  of  one  leg  may  simu- 
late the  gait  of  unilateral  dislocation,  and  the  laxity  of  the  hip- 
joint,  which  is  apt  to  come  on  in  old  paralysis  of  this  sort,  may 
tend  still  farther  to  confuse  one ;  but  the  trochanter  is  on  the 
Nelaton's  line  in  infantile  paralysis  (unless  the  joint  is  dislocated) 
and  the  leg  is  wasted  and  cold,  and  all  the  joints  grow  lax,  reflexes 
are  absent,  and  atrophy  is  most  marked. 

Congenital  hip  dislocation  is  sometimes  confounded  with  hip 
disease,  because  of  the  sprains  to  which  such  an  imperfect  joint  is 
so  liable,  which  cause  often  a  considerable  amount  of  pain.  The 
characteristic  muscular  rigidity  of  hip  disease  would  not  be  pres- 
ent, although  the  child  might  voluntarily  hold  the  affected  joint 
persistently,  and  the  characteristic  signs  of  congenital  hip  disloca- 
tion would  be  found. 

Prognosis. 

The  progress  of  the  affection,  Avhen  untreated,  is  ver\-  uncertain. 
In  certain  cases  practically  a  new  acetabulum  is  developed  with  a 
substantial  upper  rim,  the  capsular  ligament  consolidates,  and  a 
comparatively  firm  and  unyielding  joint  is  formed.  But  the  de- 
formity and  the  rolling  gait  even  in  these  cases  are  marked.     The 


5i8  ORTHOPEDIC  SURGERY. 

new  acetabulum  is  so  far  above  its  proper  place  that  with  each  step 
the  body  has  to  be  thrown  well  over,  first  to  one  side  and  then  to 
the  other.  The  amount  of  lordosis  depends  upon  the  position  of 
the  new  acetabulum,  whether  behind  or  simply  above  the  old  one. 
In  other  cases  the  disability  remains  as  great  as  in  early  childhood, 
even  if  it  does  not  increase,  the  capsular  ligament  becomes  more 
stretched,  no  new  acetabulum  of  any  practical  importance  forms, 
and  with  the  body  suspended  from  the  femurs  by  a  loose  capsular 
ligament,  the  patient  goes  through  life  walking  with  the  greatest 
discomfort  and  effort  at  each  step,  always  preserving  that  most 
characteristic  swaying  from  side  to  side. 

If  so  uncertain  a  matter  can  be  formulated,  it  may  be  said  that 
in  general  the  tendency  of  these  cases  when  untreated  is  to  remain 
stationary  or  grow  somewhat  worse. 

The  prognosis  in  cases  which  are  treated  will  be  considered 
under  that  head. 

Treatment. 

Treatment  by  Exte^ision  and  Apparatus. —  When  one  considers 
the  problem  to  be  solved  in  the  treatment  of  congenital  dislocation 
of  the  hip,  it  is  easy  to  see  why  the  remedial  means  proposed  are, 
in  general,  so  inefificient:  an  acetabulum  imperfect,  perhaps  almost 
wanting,  a  flattened  and  deformed  head  of  the  femur,  and  strong 
muscles  and  body  weight  antagonizing  every  therapeutic  measure. 

The  most  conservative  and  the  oldest  method  of  treatment  is  by 
continuous  extension.  Pravaz,  senior,  claimed  to  have  cured  a 
case  in  this  way,  but  a  committee  appointed  to  investigate  the 
case  did  not  consider  the  dislocation  reduced,  although  the  case 
was  much  benefited.'  Some  years  afterward,  Pravaz,  junior,  showed 
a  patient  for  whom  he  claimed  a  similar  result.  A  committee--  ex- 
amining the  case  again,  admitted  the  improvement,  but  denied  the 
completeness  of  the  reduction  after  two  years'  treatment.  A  com- 
mittee was  also  appointed  to  watch  cases  under  the  care  of  Gu6rin, 
who  was  treating  them  by  continuous  extension,  and  report  upon 
them,  but  the  best  that  could  be  said  was  that  2  cm.  had  been 
gained  in  one  case.  To  Dr.  Buckminster  Brown,  of  Boston,  belongs 
the  honor  of  first  having  secured  a  cure  by  this  method  of  contin- 
uous traction.^  The  case  is  unique:  a  little  girl,  four  years  old,  had 
congenital  dislocation  of  both  hips  with  loose  joints,  and  no  trace 
of  a  cotyloid  cavity  could  be  discovered    in   manipulation.     The 

*  Bull,  de  I'Acad.  de  Med.,  Paris,  vol.  iii.,  p.  408. 

=  Bull,  de  la  Soc.  de  Chir.,  1864,  218. 

3  Boston  M.  and  S.  Journ.,  June  4th,  1885. 


CONGENITAL   DJSI.OCA  TJONS. 


519 


patient  was  put  to  bed  and  traction  made  by  weights.  In  a  few 
weeks  passive  movements  were  made  hy  a  change  in  the  position 
of  the  pulleys.  hV)r  tliirteen  months  tlie  chihl  was  kept  motionless 
in  bed.  Then,  supported  by  a  wheel  crutch,  she  imitated  the  move- 
ments of  walking  without  bearing  weight  on  the  legs,  and  gradually 
she  was  allowed  to  b6ar  the  weight  of  the  body  on  her  legs.  Two 
years  and  three  months  after  the  beginning  of  treatment,  N6laton's 
line  showed  the  trochanters  in  place  and  the  walk  was  normal  and 
she  w^as  able  to  run  and  go  about  as  other  children.  The  figures 
show  the  position  of  the  child  before  and  after  treatment,  and  an 
idea  of  the  nature  of  the  apparatus 
used  may  be  gained  by  the  illustration 
(Fig.  521)  showing  the  child  in  bed 
during  the  active  treatment. 

Corsets  and  pelvic  bands  and  other 
appliances  adinfinituin  have  been  rec- 
ommended and  tried.  Konig  '  finds  a 
felt  corset  of  much  use,  because  it 
prevents  the  pelvis  from  tilting  and 
so  lessens  the  displacement  of  the  fe- 
murs. Landerer'  recommends  a  cor- 
set made  of  silicate  and  plaster  of 
Paris,  which  he  thinks  retains  in  place 
the  head  of  the  femur  and  leads  to 
a  decided  permanent  benefit.  In  one 
case  he  reduced  the  shortening  from 
6  to  2  cm.  Motta  suspends  the  pa- 
tient in  a  Sayre  sling,  and  while  the 
shortened  leg  is  pulled  down,  he  takes 

a     plaster    cast     of    the  whole     side  and        Figs.  519  and  520.— Dr.  Brown's  Patient 
from   it   makes  a   poroplastic    retaining  Before  and  After  Treatment. 

splint  which  is  worn  during  the  day,  and  at  night  a  gaiter  is  worn 
with  a  weight  attached  for  extension.  Of  this  method  Motta  says 
it  gives  "  an  immediate  correction,  or  at  least,  a  decided  lessening 
of  the  limp."^ 

Dr.  Post,  of  Boston,  has  successfully  treated  a  case  of  single  con- 
genital dislocation  of  the  hip-joint  in  the  case  of  a  young  child  by 
anaesthetizing  the  patient  and  placing  the  head  of  the  femur  in 
the  position  where  normally  the  acetabulum  would  be  found  and 
retaining  it  there  by  means  of  a  plaster  of  Paris  bandage  inclosing 
the  trunk  and  the   thigh.     This  bandage  Avas  worn  with   renewals 


Fig.  519. 


Fig.  520. 


'  "  Lehrbuch  der  spec.  Chir.,"  i88r,  vol.  iii.,  p.  2S7. 

=  Archiv  f.  klin.  Chir.,  1S85,  vol.  xxxii. ,  p.  519. 

3  Boston  jNIed.  and  Surg.  J.  (Abst.),  April  2Sth,  1SS7,  p.  39S. 


520 


ORTHOPEDIC  SURGERY. 


for  a  year,  while  the  patient  walked  about  on  crutches,  and  the 
result  was  a  thoroughly  successful  one. 

The  results  of  continuous  extension  with  modern  orthopedic  ap- 
pliances have,  in  a  measure,  yet  to  be  ascertained.  It  would  seem 
as  if  continuous  extension  with  a  long  traction  splint  ought  to 
produce  some  effect,  provided  it  could  be  continued  for  a  long 
enough   time.     The   head   of  the  bone   can   certainly  be    brought 


Fig.  521. — Apparatus  used  in  Dr.  Brown's  Case. 


down  somewhat,  and  Brown's  case  offers  a  hope  that  it  might  be 
kept  there. 

With  people  who  are  able  to  afford  the  time  and  trouble,  it 
would  seem  worth  while  in  exceptional  cases  to  attempt  a  reduc- 
tion of  the  deformity  by  Dr.  Brown's  method,  or  some  similar  one ; 
or  after  a  period  of  recumbency  and  stretching  of  the  ligaments  to 
treat  the  patient  by  means  of  a  long  traction  splint  with  rigid  peri- 
neal bands,  never  for  one  moment  allowing  traction  to  be  relaxed, 


CONGENITAL   D/SLOCAT/ONS. 


521 


and  continuing  it  for  two  years.     Practical   cx[)cricncc  alone  can 
teach  how  difficult  a  matter  that  is. 

Such  treatment  by  traction,  however,  should  not  be  begun  unless 
there  is  a  prospect  of  being  able  to  pursue  it  to  the  end.     For  the 


Fig.  523. 


Figs. 


Fig.  524. 
522,  523,  324. — Appliances  for  the  Treatment  of  Congenital  Hip  Dislocation  by  Traction 
Fig.  522. — Sitting  up.  Fig.  524. — Recumbent. 


first  result  of  traction  is  to  loosen  the  ligaments,  and  in  a  hospital 
case  seen  by  the  writers  where  the  parents  became  remiss  and  aban- 
doned treatment  after  a  few  months,  the  affected  joint  was  in  a  re- 
laxed and  disabled  condition  at  the  cessation  of  the  brief  treatment. 


522  ORTHOPEDIC  SURGERY. 

The  accompanying  pictures  illustrate  an  appliance  which  is  in- 
tended to  accomplish  the  fixation  needed  in  the  treatment  intro- 
duced by  Dr.  Buckminster  Brown,  permitting  the  patient  to  be 
carried  about  more  readily  during  the  process  of  thorough  fixation. 

It  consists  of  an  oblong  bed-frame,  which  has  already  been  de- 
scribed in  speaking  of  hip  disease  and  disease  of  the  spine,  and  the 
patient  is  fixed  upon  this  and  can  be  carried  about  readily. 
Around  the  patient's  waist  is  buckled  a  belt  with  perineal  bands 
which  exert  some  pressure  upon  the  trochanters,  and  this  is  fast- 
ened to  the  form,  and  a  band  or  iron  bar  is  attached  to  the  form 
high  enough  to  sustain  a  pull  upon  the  patient's  thigh,  when 
flexed.  This  bar  can  be  detached  if  desired.  A  broad  strap  is 
buckled  around  the  thigh,  just  above  the  knee,  and  smaller  straps 
are  attached  to  this  and  fastened  to  buckles  in  the  bar.  A  pull 
upon  these  straps  brings  the  head  of  the  femur  into  its  normal 
position  in  the  acetabulum.  When  traction  is  desired,  with  the  leg 
straightened,  this  bar  can  be  removed  and  traction  exerted  either 
by  the  ordinary  weight  and  pulley  buckled  to  the  straps  fixed 
above  the  knee,  or  instead  of  the  weight  and  pulley,  a  windlass  at- 
tachment can  be  applied  at  the  foot  of  the  frame,  while  counter- 
traction  is  made  by  perineal  straps  fastened  to  the  frame.  When 
it  is  desirable  to  allow  the  patient  to  sit  up,  the  appliance  figured 
in  the  accompanying  pictures  can  be  used  (Figs.  522-525).  It  con- 
sists of  a  leather  corset  which  encircles  the  trunk  and  is  laced  at 
the  side.  It  is  reinforced  by  a  plate  of  brass  over  the  abdomen 
and  to  it  is  attached  a  strong  iron  rod  which  passes  down  the  sides 
of  the  corset  and  is  bent  at  right  angles  at  the  bottom. 

This  is  applied  when  the  patient  is  lying  upon  the  frame,  and 
traction  is  exerted  upon  the  thighs  flexed  at  right  angles  to  the 
trunk,  while  counter  pressure  is  afforded  by  the  corset.  When 
this  is  adjusted,  efificient  traction  is  exerted  whether  the  patient  is 
lying  or  sitting,  and  the  patient  can,  therefore,  be  carried  about 
in  a  sitting  position. 

Treatment  by  Operation. — Other  methods  of  treatment  are  very 
numerous.  For  operative  means  we  have  first  the  old  operation 
of  Guerin  and  Brodhurst  by  which  Barwell  claims  to  have  secured 
two  good  results  of  late  : '  a  tenotomy  of  the  stronger  muscles 
connecting  the  femur  and  pelvis,  the  adductors,  the  rectus  anti- 
cus  femoris,  and  the  gluteus  medius.  The  knife  is  entered  subcu- 
taneously  and  section  is  made  as  close  to  the  bone  as  possible. 
Continuous  extension  is  then  maintained  for  some  weeks. 

More  radical  operative  means  have  been  tried  with  varying  re- 
sults.    Excision  of  the  head  of  the  femur  had  been  done  by  E. 

'Barwell:    Brit.  Med.  J.,  May  28th,  1887. 


CONGENITAL    DISLOCATIONS.  523 

Rose'  in  1874,  and  Ilcnsncr  '  in  i(S84  reported  a  case  successfully 
treated  by  this  method.  The  patient  was  a  girl  twenty  years  of 
age  and  in  walking  the  suffering  was  extreme.  The  head  and  neck 
of  the  femur  were  excised,  and  after  deepening  the  acetabulum  the 
parts  were  brought  into  apposition.  The  result  was  that  the  pain 
was  stopped  and  the  patient  was  able  to  go  about  by  the  aid  of  a 
cane.  Margary  ^  hoped  to  improve  on  simple  resection  and  he 
simply  chiselled  an  acetabulum  in  the  right  place  and  rei^lacing 
the  head  of  the  femur  in  it  made  a  capsule  of  periosteum  ;  but  the 
patient  died  of  pyaemia  and  Da  Paoli  '  reported  later  that  Margary 
had  returned  to  simple  excision.  Paoli  himself,  after  excising  the 
head  of  the  bone,  nailed  the  femur  to  the  pelvis  by  a  nail  driven 
through  the  trochanter  into  the  acetabulum.  He  obtained  a  good 
result,  and  a  shortening  of  some  three  inches  was  overcome,  after 
an  alarming  amount  of  fever  and  reaction.  Resection  for  congeni- 
tal dislocation  has  also  been  performed  by  Reyher.^  No  one  of 
these  results  by  operative  treatment  is  worthy  of  comparison  with 
the  result  obtained  in  Dr.  Brown's  case. 

More  recently  Molliere'^  has  reported  two  successful  cases  where 
he  cut  down  upon  the  head  of  the  bone,  scooped  out  a  new  aceta- 
bulum in  the  pelvic  bones  and  retained  the  femur  in  its  new  posi- 
tion. 

Dislocation  of  the  Other  Joints  than  the  Hip. — It  will  be  only  nec- 
essary to  mention  the  different  varieties  of  congenital  dislocation 
which  are  most  frequent,  referring  the  reader  to  such  treatises  as 
that  of  Kronlein  in  the  "  Deutsche  Chirurgie  "  for  further  elabora- 
tion of  the  matter.  In  the  spine  the  cranium  is  found  dislocated 
both  forward  and  backward  on  the  vertebral  column.'  This  occurs 
in  monstrosities.  In  others,  rotation  of  the  vertebrae  on  each  other 
is  so  excessive  as  to  constitute  a  dislocation.^ 

Dislocations  of  the  lower  jaw  are  excessively  rare.^  The  ascend- 
ing ramus  of  the  jaw  may  be  congenitally  absent  (Guy)  or  a  double 
dislocation  forward  may  be  present. 

Congenital  dislocations  have  been  noted  at  both  the  sterno-cla- 
vicular  and  acromio-clavicular  joints  (Guerin). 

Shoidders. — Congenital  dislocation  of  the  shoulder  has  been  ob- 
served in  adults  and  foetuses."     There  are  three  varieties  noted, 

'  Quoted  by  Kronlein,  loc.  cit.  -  Cent.  f.  Chir.,  1SS4,  p.  751. 

3  "  Diet.  Encyc.  des  So.  Med."  Art.  Hanche,  p.  219. 

4  Cent.  f.  Chir.,  1887,  p.  336.  s  Quoted  by  Brown. 

*  Lyon  Medicale,  1887,  No.  ix.  7  Guerin  :  Gaz.  Med.,  1S41. 

^  Fleischmann  :  "  De  vitiis  congen.  circa  Thoracera  et  Abdominem; "  also  Soemer- 
ring,"  1810.  5  Dublin  Journ.  i\Ied.  Sc,  1S42. 

^°  M.  Smith  :  Dublin  Journ.  of  Med.  Sc,  1839.  Cruveilhier:  "Anat.  Path.,"  t.  i..  p. 
475- 


524 


ORTHOPEDIC  SURGERY. 


subglenoid,  subcoracoid  and  subacromial,  or  subspinous.'  In  about 
half  the  cases  it  is  bilateral.  The  muscles  are  atrophied,  and  as  a 
rule  the  dislocated  arm  is  of  little  use. 

At  the  elbow  there  are  four  well-authenticated  varieties  of  dis- 
location. I.  Complete  dislocation  of  the  forearm  backward.  2. 
Dislocation  of  the  upper  extremity  of  the  radius  forward.  3. 
Dislocation  of  the  head  of  the  radius  upward  and  outward.'  4. 
Dislocation  of  the  head  of  the  radius  upv/ard  and  backward.^ 

At  the  wrist,  the  hand  may  be  dislocated  forward  or  backward. 
inward  or  outward  upon  the  forearm  or  any  combination  of  these 
may  be  presented. "•  It.  is  a  rare  deformity,  and  when  present,  is 
usually  found  in  connection  with  club-foot.  It  is  often  spoken  of 
as  "  club-hand  "  (main  bote). 

Luxation  5  of  the  fingers  is  occasionally  seen.  It  follows  no 
especial  rule  and  is  of  little  importance. 


Fig.  525. — Congenital  Dislocation  of  the  Knee  Forward.     (Hibon.) 

Dislocation  of  the  tibia  forward  is  the  commonest  of  all  congeni- 
tal dislocations  of  the  knee.  The  deformity  is  one  which  at  once 
attracts  notice,  because  the  knee  flexes  in  the  reverse  way  from 
the  normal.  The  limb  can  be  straightened  easily,  but  when  left  to 
itself  it  at  once  resumes  the  deformed  position. 

Of  eleven  observations  reported  by  Hibon,*  eight  were  normal 
in  other  respects  and  three  had  other  malformations.  The  former 
presented  only  unilateral  dislocation,  the  latter  dislocation  of  both 
sides. 


'  Stimson:    "  Treatise  on  Dislocations,"  p.  107;  Smitli  :    Dublin  Med.  Journal,  1839,, 

261. 

^  Bull,  de  la  Soc.  d'Anat.,  1849,  153;   Arch.  gen.  de  Med.,  3d  Serie,  t.  ix.,  p.  336. 

3  Journ.  Hebdom.,  t.  7,  1830-45. 

■♦Davaine:    Bull,  de  la  Soc.  de  Biol.,  1850,  p.  39. 

5  Berard:    "  Diet,  de  Med.,"  Art.  Main,    vol.  xviii. 

*  Hibon  :    "  Luxations  congen.  du  tibia  en  avant,"  These  de  Paris,  1881. 


'CONGKNITylL    DISLOCA  TIONS. 


52; 


When  it  is  not  associated  with  any  (jthcr  defornn'ty,  this  disloca- 
tion can  be  remedied  by  immecHate  rectification  and  retention  in 
the  straight  position.  Tlien  daily  manipulation  should  be  aj^plied 
to  flexing  the  knee  in  the  proper  directicni,  but  much  resistance 
will  be  met  at  first,  although  it  will  gradually  yield  to  gentle  force, 
and  the  foot  can  be  gradually  carried  back  as  the  anterior  liga- 
ments yield. 


Fig.  526— Congenital  Backward  Dislocation  of  the  Right  Knee.     (Children's  Hospital.) 

There  is  also  described  a  dislocation  backward  at  the  knee,  where 
there  is  a  permanent  flexion  of  the  thigh.  There  are  reported  vari- 
ous slight  modifications  of  these  forms. 

At  the  ankle,  congenital  dislocation  is  very  rare.  Krewske  re- 
ported a  case  where  the  affection  was  hereditary  and  presented  the 
external  characteristics  of  extreme  flat-foot.  Club-foot  often  ap- 
proaches the  character  of  a  dislocation. 


BIBLIOGRAPHY. 


Hip  Dislocations. 


Chaussier  :    Discourses  aux  eleves  Sages-Femmes.     Paris,  1S12. 

Vrolik  :  Mernoires  sur  quelques  Snjets  Interessants  d'Anatomie  and  Phys.  Amster- 
dam, 1822. 

Cruveilhier  :    Traite  d'Anat.  Path.  Gen.,  I.,  474.     Paris,  1S49. 

Delpech  :   Othomorphie.     Paris,  1829,  Tome  ii. 

Sedillot :    Lux.  des  Femur,  etc.     Paris,  1836. 

Von  Ammon  :    Monatscli.  fiir  Med.  Augenlieilkunde  and  Chir.,  Bd.  ii.,  p.  93,  1S39. 

R.  VV.  Keith  :    Dublin  Journal,  1839,  No.  44. 

Gerdy  :    Schmidt's  Jahrbch.,  36,  p.  263. 

Guerin  ;    Gaz.  Med.  de  Paris,  4,  1840 — 7  &  10,  1B41. 

Kleeburg  :    Schm.  Jahrbch.,  17,  334. 

Heine  :    Ueber  spont.  und  congen.  Luxationen.     Stuttgart,  1S42. 

Von  Ammon  :    Die  angebornen  chir.  Krankheiten  des  Menschen,  etc.     Berlin,  1S42. 

Petit:    These  de  Paris,  1842.     (Congenital  luxations.) 

Sanson  :    These  de  Paris,  1841.     (Congenital  luxations.) 

Adams:    Todd's  Encycl.     Arts.  Hip,  Elbow. 

Robert  :    These  de  Paris,  1851. 

Gurlt ;    Beitrage  zur  vergleich.  Path.  Anat.     Berlin,  1853. 

Mayer :  Das  neue  Heilverfahren  bei  Fcetalluxationen  durch  Osteotomie.  Wurz- 
burg,  1855. 


526  ORTHOPEDIC  SURGERY. 

Gurtz  :    Beitrag  zur  Cas.  der  angeb.  Lux.;    Inaug.  diss.     Giessen,  1855. 
Malgaigne  :    Des  Luxations.     Paris,  1855. 
Birnbaum  :    Disloc.  of  Femur;    Inaug.  Diss.     Giessen,  1B58. 
Morel,  Lavallee :    Gaz.  Med.,  1862,  4,  p.  58. 
Pravaz  (fils).     Gaz.  des  Hop.,  June  nth,  1881. 
Pravaz  (fils).     Gaz.  Hebdom.,  1864,  39  &  41. 
Zillewicz  :    Berl.  klin.  Woch.,  1869,  25. 

Gueniot  :    Des   Lux.   Coxo-femorales  soit  Congen.  soit  Spont.    au  point  de  vue  des 
Accouchements.     Paris,  i86g. 

Langgaard  :    Zur  Orthopadie.     Berlin,  1868. 
Kehrer  :    Schmidt's  Jhb.,  146. 

D'Outrelepont :    Deutsch.  Z.  f.  Chin,  1873,  Bd.  iii. 
Dalby  :    Bull,  de  Then,  April  and  May,  1873. 
Sassmann  :   Arch.  f.  Gyn.,  1873,  5.  2,  p.  241. 
Maas  :    Arch.  f.  klin.  Chir.,  1874,  17. 
Schildbach  :    Arch.  f.  klin.  Chir.,  Bd.  xxiii. ,  p.  859. 
Sayre:   Phil.  Med.  Times,  Jan.,  1876. 

Dislocations  of  other  Joints. 

Chatelain  :    Bibl.  Med.,  Ixxv.,  p.  103. 
Bard  :    Boston  Med.  and  Surg.  J.,  Nov.  26th,  1843. 
Kleeburg  :    Journal  de  Dieffenbach,  1827,  Oct. 

Moth  :    Bull,  de  I'Acad.  Roy.  de  Med.  de  Belgique,  3d  Series,  t.  x..  No.  2. 
Gueniot  :    Soc.  de  Chir.  de  Paris,  1880,  July  7th,  t.  vi.,  and  Dec.  7th,  1880. 
Perier  and  Bertin  :    Soc.  de  Chir.  de  Paris,  Dec.  7th,  1880. 
Cruveilhier  :    Atlas  de  Anat.  Path.,  2d  ed.,  Plate  II. 
Bouvier  :    Bull,  de  I'Acad.  de  Med.,  1837,  ii.,  p.  701. 

Hibon  :    These  de  Paris,  1881.     De  la  Luxation  Congenitale  du  Tibia  en  avant. 
Bouvier  :    Legons  Clin,  sur  les  Mai.  Chroniques  de  I'Appareil  Locomoteur. 
Brodhurst,  B. :    Lectures  on  Orth.  Surgery. 

Carnochan,  J.:    Etiol.,  Path.,  and  Treat,  of  Congen.  Disl.  of  the  Head  of  the  Femur. 
New  York,  1850. 

Dubreuil,  A. :    Elements  d'Orthopedie. 

Davis,  H.  G.     Conserv.  Surgery. 

Pravaz  :    Traite  The'oret.  et  Prat,  des  Lux.  Congen.  du  Femur. 

St.  Germain,  L.  A.:    Clin.  Orthop.     Lyons,  1847. 

Richardson  and  Porter  :    Bost.  Med.  and  Surg.  Journ.,  1875,  ii.,  321. 

Dubrissy  :    Cent.  f.  Chir.,  1875,  p.  624. 

Dollinger  :    Arch.  f.  klin.  Chin,  1877,  Bd.  xx. 

Reclus  :    Rev.  mens,  de  Med.  et  Chir.     Paris,  1878,  176. 

Kirmisson  :    Rev.  mens,  de  Med.  et  Chir.     Paris,  1878,  498. 

Roser  :    Verhandl.  der  Deutsch.  Gesellschaft  fiir  Chin,  1879,  8th  Congress,  p.  46. 

Kraussold  :    Cent,  fiir  Chin,  1881,  5. 

Drachmann:   Schmidt's  Jhrb.,  1881,  170, 


CHAPTER   XV. 


CONGENITAL   DEFORMITIES   OF  THE    FINGERS  AND 

TOES. 

Club-Hand. — Supernumerary  Digits. — Deficiency  of  the  Fingers  and  Toes. — 
Hypertrophy  of  the  Fingers  and  Toes. — Webbed  Fingers  and  Toes. — Con- 
genital Contractions  and  Tumors  of  the  Digits. 

Club-Hand. 

Congenital  club-hand  is  a  rare  condition,  which  is  in  a  measure 
analogous  to  congenital  club-foot.  It  is  usually  found  in  connec- 
tion with  other  deformities.  The  name  is  applied  to  a  deviation  of 
the  hand,  at  the  wrist,  from  the  line  of  the  forearm ;  and  this  devi- 
ation is  almost  always  in  ::,.,,^ 
the  direction  of  flexion.  -'v^^h^ 

In  German,  the  distortion  '■^^^i^- ';-:•, 

\s  ]inown  diS  KliuHphaud dixxd  %. 

in  French  as  main  bote.  x^ 

The     modern     classifica-       "^^~_  ■  % 

tion  of  the  distortion  is  to  '"^U;;:  % 

speak  of  the  cases  as  dor- 
sal and  palmar  club-hand, 
as  the  deformity  is  toward 
flexion  or  extension ;  or  as 
radial  and  ulnar,  or  cubital, 
as  the  deviation  is  inward 
or  outward  at  the  wrist. 
Mixed  forms  are  the  most 
common,  and  are  spoken  of 
as  radio-palmar,  etc. 

The  deformity  is,  at  best,  an  uncommon  one  and  the  dorsal 
forms  of  it  are  excessively  rare. 

The  bones  of  the  arm  may  be  normal,  but  more  commonly  the\- 
are  deformed,  or  the  radius  may  be  wanting  wholly  or  in  part. 

The  carpus  may  be  normal,  or  incompletely  developed,  or  almost 
entirely  wanting.'  When  the  radius  is  deficient,  the  lower  end  of 
the  ulna  is  enlarged  to  articulate  with  the  carpus. 

'  Bouvier:    "  Diet.  Encyc.  des  Sc.  Med.,"  Art.,  Main. 


"^ 


Fig.  527. — Club-hand  with  Deficiency  of  Part  of  Radius. 


528 


ORTHOPEDIC  SURGERY. 


A  variety  of  anomalies  of  the  muscles,  vessels,  and  nerves  may 
occur. 

Etiology. — No  satisfactory  etiological  cause  can  be  assigned  for 


Fig.  528.— Club-hand.     Dorsal  Aspect. 


the  occurrence  of  club-hand,  beyond  the  usual  explanations  urged 
to  account  for  congenital  deformities  in  general. 

Symptoms. — In  looking  at  the  palmar  varieties  of  club-hand  it  is 


Fig.  529. — Club-hand.     Palmar  Aspect. 


seen  that  the  wrist  is  sharply  flexed,  and  that,  perhaps,  the  lower 
end  of  the  radius  may  be  covered  by  the  skin  and  traversed  by  the 
extensor  tendons,  while  the  carpus  articulates  with  the  under  sur- 


FiG.  530. — Apparatus  for  the  Correction  of  Club-hand.     (After  Dubreuil.)     At  the  wrist  is  a  universal 
joint,  allowing  for  movement  or  fixation  of  the  hand  in  any  required  position. 

face  of  the  radius.  The  forearm  is  wasted,  and  if  the  radius  is 
absent,  it  appears  to  be  very  slender  indeed.  The  hand  possesses 
a  certain  degree  of  mobility  at  the  wrist,  and  when  it  is  partly  re- 


DEFORMITIES   OF    THE  FfNGFRS  AND    TOES,  529 

dressed  the  flexor  tendons  can   be   felt  to   be   rendered   tense,  and 
stand  out  under  the  skin. 

The  diagnosis  is  evident,  and  any  patliological  i)rocess  which  is 
accompanied  by  this  malposition  is  classified  as  clubdiand. 

Treatment. — In  the  worst  cases,  where  there  is  much  bony  defi- 
ciency, the  choice  lies  between  amputation  and  doing  nothing. 
The  former  measure  is  not  generally  advisable,  because,  however 
malformed  the  hand  may  be,  the  patient  finds  a  way  to  make  the 
deformed  hand  of  use,  even  though  the  distortion  is  unsightly. 

In  milder  cases,  tenotomy  of  the  resistant  muscles  or  stretching 
the  contraction  by  manipulation  or  apparatus  may  be  efficacious. 
In  general  the  decision  will  be  made  according  to  the  severity  of 
the  case. 

If  treatment  is  begun  in  early  life,  it  is  generally  possible  to  cor- 
rect the  deformity  by  bandaging  the  .hand  to  splints,  or  by  the  ap- 
plication of  a  series  of  plaster-of-Paris  bandages,  as  in  a  case  related 
by  Dr.  Sayre  in  his  "  Orthopedic  Surgery." 

Piechaud  has  recently  reported  the  case  of  a  child  three  and  one- 
half  months  old  with  double  club-hand  of  the  ulnar  variety,  which 
was  cured  by  the  mother's  manipulation  in  five  months. 

Tenotomy  is  not  advisable  if  milder  measures  are  likely  to  prove 
successful,  as  any  possible  impairment  of  the  movements  of  the 
hand  is  to  be  avoided,  and  tenotomy  of  the  extensors  and  flexors 
of  the  fingers  has,  in  a  few  instances,  led  to  loss  of  mobility  from 
non-union  of  the  tendons. 

The  hand  may  be  immediately  rectified  after  tenotomy  or  left  in 
its  former  position  and  only  put  into  proper  place  after  several 
days. 

With  proper  care,  the  results  of  treatment  are  generally  satisfac- 
tory, in  cases  where  the  bony  malformation  is  not  excessive. 

Supernumerary  Fingers. 

This  condition,  known  also  as  polydactylism,  is  of  not  infrequent 
occurrence,  and,  as  a  rule,  is  easily  remediable  by  surgical  means. 
It  frequently  occurs  as  the  result  of  inheritance,  sometimes  appear- 
ing in  every  generation,  at  other  times  skipping  a  generation  or 
two,  to  reappear  in  the  same  form  in  the  descendants  of  the  per- 
sons originally  affected. 

The  deformity  is  usually  symmetrical  and  likely  to  be  present  in 
both  hands  and  feet.  In  most  cases  there  is  only  one  extra  digit 
present  on  each  member,  but  in  some  cases  the  number  is  very 
much   in    excess   of  this.     Saviard '   saw  a  new-born   child   at   the 

'  Quoted  in  "Cooper's  Surg.  Dictionary, "  Art.  Fingers. 
34 


530 


ORTHOPEDIC  SURGERY. 


Hotel  Dieu,  in  Paris,  which  had  ten  fingers  on  each  hand  and  ten 
toes  on  each  foot,  and  a  still  more  remarkable  case  was  reported 
by  Voigt '  where  there  were  thirteen  fingers  on  each  hand  and 
twelve,  toes  on  each  foot.  The  writers  have  recently  seen  a  case 
where  there  were  fifteen  fingers  and  thirteen  toes,  many  of  the  fin- 
gers, however,  were  webbed  and  imperfect  and  the  child  was  other- 
wise malformed. 

Annandale  classifies  supernumerary  fingers  under  four  heads: 
1st.  As  a  deficient  organ  attached  loosely,  or  by  a  narrow  pedicle 
to  the  hand  or  foot,  or  to  another  digit  (Fig.  531).^ 

2d.  As  a  more  or  less  fully  developed  organ,  free  at  its  extrem- 
ity, and  articulating  with  the  head  or  sides  of  a  metacarpal,  meta- 
tarsal, or  phalangeal  bone,  which  is  common  to  it  and  another  digit. 
These  fingers  are  not  likely  to  be  sufficiently  developed  to  be  of 


Fig.  531. 


Fig.  532. 


Fig.  533. 


Fig.  534. 


much  practical  use,  but  occasionally,  as  in  the  case  shown  in  the 
figure,  the  extra  digit  was  movable  enough  to  be  of  much  service. 
Fig-  533  shows  the  most  usual  place  of  attachment  of  the  extra 
digit. 

In  the  third  variety  the  supernumerary  finger  exists  as  a  fully 
developed  organ,  having  its  own  phalanges  and  a  separate  meta- 
carpal or  metatarsal  bone.  The  figure  shows  the  bones  of  the  hand 
from  such  a  case  figured  by  Otto  (Fig.  534). 

In  the  fourth  variety  of  supernumerary  fingers,  a  more  or  less 
developed  finger  or  toe  is  found  intimately  united  through  its 
whole  length  with  another  digit  and  having  either  an  additional 
metacarpal  or  metatarsal  bone  of  its  own,  or  articulating  with  the 
head  of  one  which  is  common  to  it  and  the  other  digit.  Fig.  532 
shows  such  a  thumb  which  had  two  sets  of  phalanges,  but  only  one 
metacarpal  bone.     The  man  was  a  laborer  in  an  iron  foundry  and 


'  Forster  :     "  Missb.  des  Menschen,"  Table  8,  figs.  27  and  28. 
-  Societe  de  Med.  de  Paris,  Jan.  23d,  1875. 


DEFORMITIES    O/''    THE   !■  INC  ENS   A  i\' E    TOES. 


53' 


found  the  thumb  perfectly  useful.     The  other  figures  show  similar 
deformities  in  the  great  toe  and  thumb. 

Finally  must  be  mentioned  a  very  rare  deformity  of  the  hand. 
It  consists  of  a  bifurcation  of  the  hand,  of  which  two  cases  at  least 
have  been  reported.' 

Treatment. — Usually  it  is  desirable  to  remove  an  extra  finger  as 
early  as  practicable  where  removal  is  i)0ssible,  as  the  sooner  the 
operation  is  performed  the  less  noticeable  will  be  the  scar.  Tiiere 
is  often  a  chance  that  the  supernumerary  finger  may  be  of  use  if 
left  in  place;  but  persons  thus  afflicted  are  usually  sensitive  as  to 
the  malformation. 

Except  in  the  first  variety  of  supernumerary  digits,  it  is  not  ad- 
visable to  undertake  an  operation  for  the  removal  of  extra  toes  unless 
they  cause  very  decided  deform- 
ity of  the  foot. 

The  first  variety  of  supernu- 
merary fingers  or  toes  should  be 
removed  close  to  the  skin,  and 
one  or  two  sutures  taken  to  con- 
trol the  arterial  bleeding. 

In  operating  upon  the  second 
variety,  a  more  serious  question 
arises,  because,  where  the  two 
digits  share  the  same  articulat- 
ing surface,  it  is  often  necess- 
ary to  open  the  synovial  capsule  of  the  adjacent  finger;  but  with 
proper  asepsis,  the  risk  of  injuring  the  usefulness  of  other  fingers 
is  slight.  If  the  metacarpal  bone  is  broadened  or  bifurcated  to 
articulate  with  the  two  sets  of  phalanges,  it  may  be  desirable  to 
chisel  away  part  of  the  metacarpal  band,  rather  than  leave  a  bony 
prominence  under  the  skin.  Occasionally  the  amputated  finger  is 
reproduced,  as  in  a  very  remarkable  case  quoted  by  White,  where 
a  supernumerary  thumb  was  twice  amputated  and  each  time 
reappeared  in  its  original  form,  even  to  the  reproduction  of  the 
nail." 

In  the  third  and  rare  variety,  where  a  fully  formed  finger  and 
metacarpal  bone  are  present,  the  only  operation  is  the  ordinary 
amputation  of  one  finger  and  the  metacarpal  bone,  which  leaves  a 
serious  scar  and  weakens  the  hand. 

In  the  fourth  variety,  sometimes  the  double  fineger  can  be  sepa- 
rated into  its  two  components  and  one  of  them  removed ;  but  gen- 

'  Murray:  Med.-Chir.  Transactions,  London,  1S65;  Giraldes ;  "Mai.  Chir.  des 
Enfants,"  Paris,  1865. 

■■^  "  On  the  Regeneration  of  Animal  Substances,"  C.  White. 


Fig.  536. 


Fig.  537. — Bifurcation  of 
the  Hand. 


532 


ORTHOPEDIC  SURGERY. 


erally  this  is  not  possible,   and  it  is,  as  a  rule,  better  either  to  let 
the  finger  alone,  or  to  amputate  it  altogether. 

■  Congenital  Deficiencies  of  Fingers  and  Toes. 

These  deformities  consist  in  a  diminution  in  either  the  number 
of  the  fingers  or  in  the  number  and  bulk  of  the  segments  compos- 
ing the  digits,  and  most  often  these  two  conditians  coexist.  As  a 
rule,  other    deformities   of   the   extremities   are   also   present.     In 


Fig.  538. 


Fig.  539. 


Fig.  540. 


some  cases  the  loss  of  some  of  the  fingers,  or  of  the  whole  extrem- 
ity is  the  result  of  intra-uterine  amputation,  and  at  times,  from  the 
ends  of  such  stumps  rudimentary  digits  seem  to  have  sprouted  ;  at 
other  times  the  condition  of  webbed  fingers  is  so  closely  associated 
with  this,  that  it  is  almost  impossible  to  separate  the  two. 

The  figures  show  more    plainly  than   can  any  description,  the 
common  types  of  the  deformity. 

As  regards  treatment,  there  is  little  to  be  done,  except  in  certain 
cases  to  undertake  plastic  operations  in  order  to  diminish  the  un- 
sightliness  of  such  hands.  Webbed  fingers  may  be  separated,  use- 
less stumps  of  fingers  removed,  and  some- 
times the  patient  will  prefer  to  undergo  am- 
putation of  the  whole  hand  to  retaining  an 
unsightly  and  useless  member. 


Hypertrophy  of  the  Fingers  or  Toes, 

This  is  a  condition  which  is  occasionally 
encountered,  but  which  is  decidedly  rare.  It 
is,  perhaps,  noted  at  birth  that  one  digit  is 
larger  than  the  rest,  and  with  the  growth  of 
the  hand  this  abnormally  large  finger  remains  proportionately  the 
same,  growing  more  rapidly  than  the  other  fingers.  It  is  a  hyper- 
plasia of  all  the  structures,  although  sometimes  more  marked  in  the 
muscular  and  areolar  tissues  than  in  the  others.     The  arteries  going 


Fig.  541. 


DEFOKMITII'IS   OF    THI'.    I'JNCI'IRS   AXI)    TO/CS. 


533 


to  these  fingers  arc  larger,  and  tlic  temijcrature  In'gher  than  in 
the  normal  fingers.  The  figure  shows  the  appearance  presented  by 
such  a  hand  (Fig.  541). 

Treatment. — No  treatment  short  of  amputation  can  be  recom- 
mended. Continued  comi)ression  has  rendered  no  assistance,  and 
it  is  doubtful  if  ligation  of  the  arteries  of  the  finger  will  prove  ben- 
eficial, although  the  measure  has  been  tried,  without  success,  as  far 
as  has  yet  been  reported. 

Webbed  Fingers  and  Toes. 


This  constitutes  a  more  or  less  common  condition,  known  more 
scientifically  as  syndactylism.  Two  or  all  of  the  fingers  may  be 
connected  together  throughout  all  or  part  of  their  length.  The 
fingers  at  the  inner  side  of  the  hand  seem  more  frequently  involved 


Fig. 


Fig.  544.  Fig.  545. 

Types  of  Syndactylism. 


Fig.  546. 


than  the  others.  It  is  easy  to  see  how  the  condition  arises  if  it  be 
borne  in  mind  that  the  fingers  are  form^ed  in  the  embryo  b}-  the 
formation  of  grooves  which  become  clefts,  dividing  up  the  rounded 
extremity  which  originally  existed. 

The  bond  of  union  of  the  digits  may  consist  of  only  a  web  of 
skin  and  areolar  tissue,  as  shown  in  the  figure,  or  the  fingers  may 
be  more  intimately  fused  together  by  muscular  and  fibrous  tissue 
as  well  as  the  skin ;  or  finally  the  bones  of  two  fingers  may  be 
fused  together,  through  their  whole  length  exceptional!}-,  more 
commonly  only  at  the  two  terminal  phalanges. 

In  either  of  the  varieties,  the  union  of  the  fingers  may  be  com- 
plete through  their  whole  length,  or  only  at  the  terminal  portion. 

Treatment. — The  objection  to  simply  dividing  the  web  from  top 


534 


ORTHOPEDIC  SURGERY. 


to  bottom,  as  was  formerly  done,  is  that  in  healing  it  is  almost  im- 
possible to  keep  a  certain  portion  of  the  web  from  reforming  by 
cicatricial  contraction,  especially  at  the  commissure  between  the 
fingers.  Even  when  every  care  was  taken  to  keep  the  fingers  apart 
by  strips  of-  oiled  lint,  etc.,  the  results  were  not  always  satisfactory, 
and  the  separation  of  the  fingers  was  incomplete,  on  account  of 
this  contraction  of  the  scar. 

The  first  operation  undertaken  to  remedy  this  defect,  was  to 
cause  a  permanent  opening  at  the  bottom  of  the  web  before  cutting 
the  web  itself,  by  transfixing  the  lower  part  of  it  with  a  rubber 
cord,  or  silver  wire  fastened  at  both  ends  to  a  tape.  This  method, 
has,  however,  been  superseded  (except  in  very  simple  cases)  by 
more  accurate  and  thorough  measures. 

Didot's  operation '  is  the  one  most  in  use.     The  method  is  evi- 


FiG.  547. — Didot's  Operation  for  Syndactylism. 


Fig.  548. — Didot's  Operation  for  Syndac- 
tylism, Represented  in  Cross  Section. 


dent  from  a  glance  at  the  figure,  and  no  extensive  description  is 
required.  An  incision  is  made  along  the  middle  of  the  palmar 
surface  of  one  finger  reaching  from  the  base  to  the  top  of  the  web, 
and  is  joined  at  each  end  by  transverse  incisions  which  reach  to 
the  middle  of  the  adjacent  finger.  The  same  process  is  repeated 
on  the  dorsum  of  the  two  fingers,  except  that  the  flap  runs  in  the 
opposite  direction.  After  these  skin  flaps  are  made,  the  remaining 
tissues  of  the  web  are  divided,  and  the  dorsal  flap  of  one  finger 
covers  the  palmar  surface  of  the  other,  as  shoAvn  in  the  cross  sec- 
tion. The  flaps  should  not  be  made  too  broad.  In  this  way  no 
raw  surfaces  are  in  apposition  and  the  danger  of  recontraction  is 
much  diminished,  although  the  interdigital  cleft  must  always  be 
watched,  as  these  contractions  sometimes  begin.     The  technique  of 

'  Bull,  de  I'Acad.  de  Med.  deBel.,  March  23d,  1850,  lix.,  351. 


DEFORMITII'lS    ()/•'    11 1  hi   I'lNCh.RS   AND    TOI-'S. 


535 


this  operation  is  simple,  except  wliere  tlie  liaixl  is  very  small,  when 
it  may  become  decidetUy  (lifficult.  I'or  this  reason  it  is  well  to 
wait  until  the  child  is  at  least  four  or  five  years  old  before  operat- 
ing. The  operation  is  only  suitable  in  cases  where  the  web  ex- 
tends the  whole  length  of  the  fingers,  and  if  the  fingers  are  very 
intimately  fused  it  will  not  be  possible  to  obtain  flaps  long  enough 
to  serve  the  purpose.  At  the  commissure  of  the  fingers  it  is  dififi- 
cult  to  adjust  the  sutures  quite  satisfactorily,  and  it  is  here  that  one 
must  carefully  guard  against  a  relapse.  Attention  should  be  called 
to  the  fact  that  no  two  adjacent  fingers  are  of  the  same  volume, 
and  that  in  cutting  the  flaps  this  fact  must  be  borne  in  mind. 


Fig.  549. — Zeller's  Operation  for  Webbed  Fingers.        Fig.  550. — Norton's  Operation  for  Webbed  Fingers. 


The  operation  of  Zeller  is  another  plastic  method,  especially  ap- 
plicable to  the  class  of  cases  where  the  web  is  incomplete.  Two 
incisions  A  and  B,  are  made,  as  shown  in  the  figure,  meeting  at  the 
point  C,  the  skin  included  between  these  incisions  is  then  dissected 
up  and  reflected  as  the  flap  E,  and  the  web  is  divided.  The  fingers 
are  then  separated  and  the  flap  E  carried  forward  between  the 
fingers  and  fixed  to  the  palmar  surface  between  the  cleft.  In  this 
way  a  commissure  of  sound  skin  is  provided. 

Norton's'  operation  is  a  modification  of  the  earlier  proceeding 
of  Dece.  Small,  rounded,  anterior  and  posterior  flaps  are  made 
at  the  clefts  between  the  fingers  with  their  bases  opposite  the  heads 
of  the  metacarpal  bones,  the  Aveb  is  then  divided  and  the  flaps 
joined. 

^  British  iNIedical  Journal,  August,  iSSi. 


536  ORTHOPEDIC  SURGERY. 

In  general,  it  may  be  said  that  where  the  web  is  small  ajid  thin 
or  where  the  union  between  the  fingers  is  very  close,  the  best 
method  will  be  to  cause  a  permanent  opening  at  the  base  of  the 
web  as-  described,  and  later  to  divide  the  web  from  top  to  bottom, 
suturing  the  incision  along  the  inner  border  of  each  finger  if  it  can 
be  done.  Where  the  web  is  more  extensive,  Didot's  operation  is 
the  best,  but  where  the  Aveb  is  incomplete  and  reaches,  perhaps, 
only  to  the  end  of  the  first  phalanx,  Zeller's  will  give  better  results. 
Norton's  is  applicable  to  much  the  same  class  of  cases  as  Zeller's. 

Congenital  Contractions  and  Tumors  of  the  Fingers  and 

Toes. 

Congenital  contractions  of  the  fingers  and  toes  are  rare.  They 
are  often  not  noted  at  birth,  but  only  observed  when  the  child 
begins  to  use  the  hands  or  feet.  The  figure  shows  the  photograph 
of  the  hand  of  a  child,  recently  seen  by  the  writers  where  there  was 
a  rigid  flexion  of  the  three  ulnar  fingers  in  each  hand.     These  con- 


ijii^iiMi 


Fig.  5SI. — Congenital  Contraction  of  the  F'ingers  of  one  Hand,  in  a  Child  Two  Years  Old. 

genital  contractions  may  be  due  to  defective  development  of  the 
bones  or  to  shortening  of  the  muscles  or  fasciae. 

They  are  not  uncommonly  observed  in  the  toes,  where  some 
other  than  a  congenital  cause  receives  the  credit  for  them.  In 
some  cases  of  this  sort,  Mr.  Annandale  was  able  to  establish  an 
hereditary  history  of  such  deformity,  and  proved  to  his  own  satis- 
faction, that  many  of  these  cases  were  of  congenital  origin.  Gen- 
erally these  contractions  are  in  the  flexed  position,  but  digits  may 
be  hyperextended,  especially  in  the  case  of  the  toes. 

Two  such  contracted  toes  may  be  seen  in  Fig.  522,  with  a  sec- 
tion of  one  showing  the  dislocation  which  was  present  as  a  result 
of  the  very  severe  contraction. 

Treatment. — Massage  and  manipulation  should  be  first  employed 


D/CFUA'Af/TI/CS    <)/'•    rill']    /■INiih'.RS   AND    TOES. 


537 


in  cases  of  contraction,  as  the  contraction  will,  in  some  instances, 
yield  to  these  means,  especially  in  the  fingers.  If  this  fails,  tenot- 
omy, or  division  of  the  contracted  fas- 
^cia,  or  amputation  of  the  contracted 
finger  or  toe,  will  be  the  measure  indi- 
cated. 

Lateral  deviation  of  the  fingers  some- 
times occuj-s  to  a  very  marked  extent 
either  after  accident  or  disease.  It  may 
be  amenable  to  treatment  by  apparatus 
or  osteotomy. 

Congenital  tumors  which  affect  the 
fingers  and  toes  are  classified  by  An- 
nandale  as  follows : 

1.  Pedunculated  growths  or  excres- 
cences of  the  skin. 

2.  Fatty  growths. 

3.  Fibrous  growths. 

4.  Cartilaginous  growths. 
They  are  very  rare  and  their  treat- 
ment should  be  conducted  upon  gen- 

,  .       ,  ...  Fig.  552. — Congenital  Deformities 

eral  surgical  prmciples.  oftheXoes. 


CHAPTER   XVI. 
INFANTILE  SPINAL  PARALYSIS. 

Definition. — History.—  Etiology. — Pathology. —  Symptoms. —  Diagnosis. — Dif- 
ferential Diagnosis. — Prognosis. — Treatment. 

Infantile  spinal  paralysis  is  an  affection  which  attacks  chiefly 
children  in  their  first  dentition.  It  comes  on  with  a  sudden  onset 
and  deprives  certain  muscles  and  often  an  entire  limb  of  muscular 
power  and  the  parts  affected  undergo  rapid  atrophy.  The  paraly- 
sis is  a  purely  motor  one. 

The  pathological  name  of  the  affection  is  acute  anterior  poliomy- 
elitis, and  other  common  names  are: 

Infantile  paralysis,  essential  paralysis  of  children,  acute  atrophic 
spinal  paralysis,  "  teething  palsy  "  or  dental  paralysis.  Regressive 
paralysis  (Barlow),  myelitis  of  the  anterior  horns  (Seguin),  myo- 
genic paralysis  (Bouchut). 

German :  Kinderlahmung,  or  spinale  Kinderlahmung,  or  essen- 
tielle  Kinderlahmung. 

French :  Paralysie  spinale,  paralysie  infantile,  paralysie  des  pe- 
tits  enfants,  paralysie  essentielle  de  I'enfance,  tephromyelite  ante- 
rieure  aigue  (Charcot),  paralysie  atrophique  graisseuse  de  I'enfance,, 
etc. 

History. 

The  disease  was  first  mentioned  by  Underwood'  in  1784,  but  it 
was  not  then  separated  clearly  from  the  other  kinds  of  paralysis 
affecting  children,  and  it  remained  for  Heine  to  give  the  first  ac- 
curate account  of  the  disease  in  1840.  The  latter  was  followed  by 
Barthez  and  Rilliet  in  i85i,the  two  Duchennes,  Barlow,  Seelig- 
miiller  and  a  very  large  number  of  later  writers. 

Etiology. 

Little  is  known  of  the  causation  of  infantile  paralysis.     The  dis- 
ease is  usually  limited  to  the  time  of  the  first  dentition  in  children. 
'  "  Treatise  on  the  Diseases  of  Children,"  London,  7th  ed.,  1826,  p.  251. 


INFANT/ /JC  S/'/NAL    PARALYSIS.  539 

Of  250  cases  (collected  from  Ilcim;,'  JJuchennc  tlic  younger,-  and 
Barlow  3)  154  occurred  between  6  months  and  2  years.  Of  Seelig- 
miiller's'  71  cases,  90  per  cent  occurred  before  3  years,  and  of  150 
cases  considered  by  Sinkler^  six-sevenths  of  all  cases  occurred  in 
the  first  3  years.  Inasmuch  as  it  is  well  known  that  children  are 
especially  irritable  and  liable  to  neuroses  of  all  sorts  durinj^^  the 
time  of  dentition,'^  it  is  assumed  that  this  condition  of  exalted 
nervous  irritability  is  sufificient  to  render  the  cord  most  susceptible 
to  any  irritation,  such  as  a  sudden  chan^^e  of  the  surface  tempera- 
ture of  the  body  as  by  sudden  coolin^^  of  the  heated  surface.  The 
disease  has  been  seen  as  early  in  life  as  the  twelfth  day  in  a  case 
of  Duchenne's  and  adults  are  not  exempt  from  a  similar  affection, 
which  is  occasionally  of  traumatic  origin. 

Exposure  to  severe  heat  and  sunstroke  are  mentioned  as  occa- 
sional causes  of  the  attack  of  paralysis.  Most  cases  occur  during 
warm  weather.  27  of  Barlow's  53  cases  occurred  during  July  and 
August,  and  Sinkler  found  that  in  47  out  of  57  cases  the  disease 
occurred  in  the  warm  months. 

Exposure  to  cold,  or  chilling  of  the  heated  body,  and  sitting  on 
the  damp  grass  or  on  cold  stones,  are  mentioned  as  common  causes 
of  the  attack  of  paralysis.  An  interval  of  two  or  three  days  be- 
tween the  exposure  and  the  paralysis  is  frequently  mentioned. 
Over-exertion  is  reported  as  an  occasional  cause  of  the  affection. 
The  disease  is  also  known  to  occur  during  or  soon  after  measles,'' 
scarlet  fever,^  vaccinia,  and  typhus  and  typhoid  fever,  pneumonia, 
and  erysipelas.'  An  acute  feverish  attack,  like  indigestion,  is  often 
assigned  as  the  cause,  but  inasmuch  as  it  is  ordinarily  the  chief 
symptom  of  the  onset,  no  weight  can  be  attached  to  it. 

Certain  other  cases  seem  to  come  on  after  a  fall,  and  it  is  quite 
possible  that  a  traumatic  hemorrhage  into  the  substance  of  the 
cord  might  occur,  causing  much  the  same  symptoms  as  anterior 
poliomyelitis,"  but  such  traumatic  histories  are  rare,  though  they 
are  in  children  more  common  than  in  adults. 

As  a  matter  of  fact,  the  disease  attacks  healthy  and  unhealthy 

^  Heine  :   "  Ueber  Sp.  Kinderlahmung,"  2  Aufl.,  Stuttgart,  1S60. 

-  Duchenne  fils  :  Arch.  Gen.  de  Med.,  Tome  ii.,  1S64. 

3  Barlow:    "On  RegTessive  Paralysis,"  London,  1S7S. 

^Seeligmiiller:    Gerhardt's  "  Handbuch  der  K'hten,"  v.,  iSSi,  p.  i. 

s  Wharton  Sinkler:   Am.  Journ.  Med.  Sci.,  April,   18S5. 

*  Henry  Kennedy:    Dublin  Quart.  Journ.,  ix. ,  Feb.  and  jNIay  ;  xxii.,  Aug.  and   Xov. 

7  Seeligmiiller:    Loc.  cit. 

^  Roger:    Gaz.  Med.,  1S71. 

9  Meyer:    "  Die  Electricitat  und  ihre  Anwendung  auf  pract.  Medicin,"   Berlin,   1S6S, 
3ded. 

'°  Taylor:    Med.  Times  and  Gazette,  1S79,  vol.  i. ,  p.  187;    Duchenne:    Arch.  Gen.  de 
Med.,  1864;  Kennedy:  Dublin  Quarterly,  1S50,  and  Frey :  Berl.  klin.  Woch.,  1S74.   . 


540 


OR  THOPEDIC  S  UR  GER  Y. 


children,  boys  and  girls  alike,  usually  without  any  assignable  cause, 
coming  on  in  the  midst  of  perfect  bodily  health,  and  apparently  the 
affection  has  no  dependence  upon  a  hereditary  influence.'  It  is  by 
far  the  commonest  paralysis  in  children^  and  in  most  cases  develops 
during  the  night  rather  than  the  day  and  commonly  during  the  hot 
months. 

A  suggestion  ^  has  recently  been  made  that  infantile  paralysis, 
as  well  as  epilepsy,  is  an  infectious  disease  and  is  caused  by  a 
microbe.  The  evidence  for  this  seems  to  rest  largely  upon  a  paper 
by  Mathis/ who  shows  that  the  "  maladie  des  jeunes  chiens "  is 
caused  by  a  microbe  unquestionably.  This  affection  is  an  eruptive 
disease  accompanied  by  paralysis  which  affects  puppies,  as  its  name 
implies.  Further  evidence  must  be  adduced  before  such  a  theory 
receives  any  general  acceptance. 

Pathology. 

Infantile  paralysis  is  a  destructive  inflammation  of  the  large  mul- 
tipolar ganglion  cells  in  the  anterior  cornua  of  the  cord.  The 
lesion  is  apt  to  be  diffused  through  the  cord,  but  it  reaches  its 
greatest  intensity  in  the  cervical  and  lumbar  enlargements,  where 
the  permanent  alterations  caused  by  it  are  chiefly  noticeable. ^ 

It  seems  probable  (although  not  supported  by  many  pathological 
facts)  that  the  first  change  is  a  congestion  of  the  cells,*  followed  by 
an  acute  parenchymatous  inflammation  ^  and  subsequent  atrophy 
of  the  cells.  Several  early  autopsies  have  been  recorded,^  but  only 
one  early  enough  to  throw  much  light  upon  the  changes  of  the 
initial  stage.' 

In  general  it  may  be  said  that  the  cord  presents  but  slight 
changes  in  gross  appearance  if  the  autopsy  is  made  within  two  or 

^  Gowers:    "  Dis.  of  Nerv.  Syst.,"  vol.  i.,  253. 
^  Jacob  V.  Heine:    Loc.  cit. 

3  N.  Y.  Med.  Jour.,  Nov.  17th,  1888,  p.  550. 

4  Recueil  de  Med.  Veterinaire,  April  15th,  1887. 

s  Cornil:  Comptes  rend,  de  la  Soc.  de  Biol.,  1864,  p.  187  ;  Prevost:  Comptes  rend,  de 
la  Soc.  de.  Biol.,  1866,  p.  215  ;  Clarke  :  Medico-Chir.  Trans.,  li.,  186S,  p.  249  ;  Charcot 
&  Joffroy:  Arch,  de  Phys.,  iii.,  1870,  p.  134. 

*  Adamkiewicz:  Stzgsberichte.  der  k.  Akad.  der  Wiss.,  Wien,  Ixxxiv.,  iSSi  ; 
Ixxxv.,  1882. 

7  Charcot:    "  Lecons  sur  les  mal.   du  syst.  nerv.,"  1877,  i.  p.  776. 

^  Schultze  :  Neurologisches  Centralblatt,  i.,  1882,434;  Taylor:  Path.  Soc.  Trans., 
XXX.,  1879,  197;  Rinecke:  Jhrb.  f.  Khde.,  N.  F.,  v.,  1871,  118,  and  Berl.  kl.  Woch.,  1871, 
viii.,  627;  Humphreys:  Path.  Soc.  Trans.,  London,  xxx.,  1879,  211;  Roger  &  Damas- 
chino:  Gaz.  Med.,  1871,  and  Virch.  Jhresb.,  ii.,  1871,  p.  35  ;  Roth:  Virch.  Archiv,  Iviii., 
1873,  263  ;  Leyden  :  Arch.  f.  Psych.,  vi.,  1876,  271  ;  Parrot  &  Joffroy :  Arch,  de  Physiol., 
iii.,  1869,  309. 

.  9  Brain,  April,  1885. 


infantile:  s/'/n,i/.  r.  i na l  \  s/s. 


541 


three  years  of  the  onset  of  the  disease;  if,  liowever,  the  disease  has 
existed  for  several  years,  the  affected  side  of  the  cord  is  seen  to  be 
decidedly  smaller  than  the  other,  the  anterior  columns  are  shrunken, 
and  the  white  columns  are  seen  to  be  atrf)i)hied  and  sclerosed.  On 
microscopic  investigation,  however,  changes  are  seen  at  an  early 
period  of  the  disease.  The  diseased  area  is  found  to  occupy  part 
or  the  whole  of  an  anterior  cornu,  and  longitudinally  to  involve  a 
varying  extent  of  the  cord.  In  the  diseased  areas  the  tissue  is  fria- 
ble and  soft  and  contains  many  granulation  cells,  with  an  increase 
of  connective  tissue. 

The  ganglion  cells  are  seen  in  all  stages  of  degeneration  and 
atrophy.  The  nerve  fibres  and  axis-cylinders  have  completely 
disappeared  and  diffused  changes  are  to  be  seen  beyond  the  areas 
which  are  directly  affected.  Later  examinations  show  merely  an 
increase  of  the  same  condition,  and  the  horn  of  the  affected  side  is 
shrunken  or  completely  destroyed,  its  place  being  taken  by  a  mass 
of  connective  tissue.  The  anterior  nerve  roots  are  smaller  than 
those  of  the  other  side  and  are  atrophied. 

Certain  cases  of  hemorrhage  into  the  anterior  cornua  probably 
pass  for  anterior  poliomyelitis  and  such  cases  are  related  by  All- 
butt  '  and  Turner.-  A  traumatic  origin  of  the  paralysis  should, 
therefore,  be  suspected  where  the  attack  comes  on  immediately 
after  a  fall  or  at  a  more  remote  time. 

Atrophic  changes  soon  take  place  in  the  paralyzed  limb.  Some- 
times the  atrophy  affects  the  bones,  which  become  shortened  even 
to  the  extent  of  affecting  the  length  of  a  limb  by  several  inches. 
At  the  same  time  the  affected  limb  grows  comparatively  smaller 
in  circumference  than  that  of  the  opposite  side.  This  is  frequently 
the  result  of  retarded  growth  rather  than  of  real  Avasting,  but  both 
factors  at  times  enter  into  the  change.^  In  other  instances,  even  in 
severe  cases,  the  bones  seem  but  little  affected,  while  the  atrophy 
of  the  muscles  is  very  marked. 

The  epiphyses  are  stunted,  and  the  ligaments  become  thin  and 
loose  and  dislocations  and  distortions  of  the  joints  are  favored.  It 
is  in  the  muscles  that  the  most  notable  changes  are  found.  These 
waste  rapidly  and  become  flabby  to  the  touch  ;  and  microscopic 
examination  shows  a  loss  of  striation  followed  by  a  granular  de- 
generation of  the  fibres  until  little  is  left  beyond  muscle  corpuscles 
and  fat  granules  contained  in  sarcolemma.  This,  of  course,  is 
clearly  more  than  the  atrophy  of  disuse. 

'  Allbutt:    Lancet,  1870,  ii.,  84. 
^  Turner:    Trans.  Path.  Soc,  xxx.,  1879,  p.  202. 

3  SeeligmiiUer  :    Loc.  cit. ;   Volkmann  :    "  Sammlung  Klin.  Vortr. ,"    1S70  ;    "  Ueber 
Kinderliihmung  und  Paralytisch.  Contracturen." 


^42  ORTHOPEDIC  SURGERY. 

The  conclusion  from  the  pathological  evidence  is  that  in  gen- 
eral the  process  is  inflammatory  in  character  with  degeneration  of 
the  motor  nerve  fibres,  secondary  to  the  lesion  of  the  motor  cells. 
In  rare  cases  the  lesion  is  vascular,  when  the  appearances  are  those 
of  a  primary  hemorrhage  rather  than  of  a  hemorrhagic  myelitis. 

The  brain  is  almost  always  found  normal.  Sanders  reported 
one  case  where  after  many  years  of  paralysis,  slight  cerebral  atro- 
phy was  found. 

Symptoms. 

In  general  the  clinical  history  of  the  disease  falls  into  three 
stages. 

{a)  The  onset,  to  which  stage  belong  the  acute  febrile  symptoms 
and  the  development  of  paralysis. 

{b)  The  stage  of  convalescence,  which  begins  at  the  time  of  the 
full  development  of  the  paralysis,  and  is  followed  by  a  brief  station- 
ary period,  and  finally  rapid  and  then  slower  improvement  until  a 
stationary  period  is  reached. 

[c)  The  stage  of  deformity.  Where  wasting  of  the  affected  limb 
is  present  and  static  and  paralytic  and  contraction  deformities 
have  supervened. 

No  arbitrary  subdivision  of  the  classes  of  symptoms  has  been 
made,  because  in  reality  the  stages  run  into  each  other  so  gradually 
that  it  seems  unjustifiable  to  do  so  practically. 

Infantile  paralysis  is  oftenest  ushered  in  by  a  mild  or  severe 
febrile  attack,  which  presents  no  definite  characteristics  to  distin- 
guish it  from  any  ordinary  attack  of  cold  or  indigestion.'  The 
elevation  of  temperature  is  not  excessive,  commonly  ioo°  to  102° 
F.,  sometimes  even  104°.  With  this  fever  are  apt  to  be  associated 
vomiting,  convulsions,  giddiness  or  other  cerebral  disturbance, 
sometimes  even  delirium.  Older  children  complain  of  pain  in  the 
back  and  limbs.  There  is,  as  a  rule,  no  warning  of  the  attack, 
although  Seeligmiiller  has  noted  at  times  a  disinclination  to  walk 
or  stand  as  much  as  usual  for  some  days  preceding — a  fact  quite  in 
accordance  with  Lange's  theory  that  over-exertion  of  the  muscles 
has  much  to  do  with  the  production  of  the  disease.  Convulsions 
are  present  in  about  15  per  cent  of  all  the  cases,'^  and  when  they 
occur,  they  are  usually  followed  by  a  period  of  unconsciousness. 
The  feverish  attack  at  the  onset  may,  however,  be  very  severe,^ 
at   times    lasting  two    or    three   days   (or   even  weeks)   before  the 

^  Vogt:   "  Ueber  die  Essentielle  Lahmung-  der  Kinder." 
^  Jacobi :    "  Pepper's  Syst.  of  Medicine,"  vol.  ii. 

■'Erb:   Ziemssen's  "  Hdbch.,"  xi.,  12;  Henoch:  "  Vorles.    iiber  Khten.,"  2d  Aufl., 
1881. 


INF  ANT  I  LI':  SJ'INAL   PANALYSIS. 


543 


paralysis  appears.  More  commonly,  liowcvcr,  il  is  very  slight  and 
scarcely  noticed.  In  certain  rare  cases,  two  or  even  tiiree  '  attacks 
of  fever  are  noted,  each  followed  by  an  increase  in  the  paralysis." 
Pain  of  a  rheumatic  character  in  the  hack'  and  limbs  is  a  common 
initial  symptom.^ 

In  certain  cases,  however,  and  n(;t  very  rarely,'  all  feverish  and 
other  symptoms  are  absent  ^  at  the  onset,  and  the  child  is  suddenly 
discovered  to  be  paralyzed  in  one  or  more  limbs.  Such  paralysis 
comes  on  oftenest  in  the  night,  but  it  has  been  observed  to  come 
on  quietly  in  the  daytime,  while  the  child  was  at  play.'''  In  these 
cases  there  may  be  no  succeeding  illness,  and  the  paralysis  is  the 
only  symptom  throughout. 

Diarrhoea,  vomiting,  general  hyperaesthesia,  and  much  nervous 
irritability  are  other  symptoms  which  often  accompany  the  onset 
of  the  paralysis.  During  the  first  few  days  there  may  be  paralysis 
of  the  bladder  with  retention  or  incontinence  of  urine,  but  it 
always  disappears  after  a  few  days  or  weeks. 

Pain  is  a  symptom  but  little  noted  in  infantile  paral}'sis,  but  it  is 
not  uncommon,  nor  does  it  indicate  of  itself  the  presence  of  any 
additional  pathological  process. 

The  paralysis  itself  very  quickly  becomes  manifest  and  reaches 
its  maximum  within  a  few  hours  of  the  attack,  or  within  a  day  or 
two,  except  in  rare  cases.  Having  reached  its  maximum  and  re- 
mained stationary  for  a  short  time,  improvement  almost  invariably 
begins.  In  rare  cases  improvement  begins  immediately  after  the 
attack,  and  proceeds  to  complete  recovery.  These  are  the  cases 
which  are  spoken  of  as  "  temporary  spinal  paralysis."  The  more 
common  course  is  for  the  paralysis  to  remain  nearly  stationary  for 
a  time,  varying  from  two  to  six  weeks  and  then  to  improve,  at  first 
rapidly  and  then  more  slowly,  for  three  or  four  months.  After  six 
months  have  passed,  further  spontaneous  improvement  is  unusual. 

Vascular  changes  become  very  marked.  The  temperature  of  the 
limb  is  much  lower  than  that  of  the  other,  even  20°,  30°,  or  40°  F. ; 
Hammond  speaks  of  a  case  whose  surface  temperature  was  75°  in 
a  room  of  72°.  The  limb  is  bluish,  with  a  superficial  stagnation  of 
the  blood,  on  account  of  an  atrophy  of  the  blood-vessels  and  con- 
sequent diminution  of  their  calibre,  and  when  the  blood  is  pressed 
out  of  the  surface  capillaries  by  the  finger  it  returns  slowly.     On 

'  Laborde:    Op.  cit.,  p.  8. 

^  Althaus:    "  On  Inf.  Par.  and  some  allied  Diseases  of  the  Sp.  Cord,"  London,  1S7S 
p.  12. 

3  Duchenne,  fils  :    Arch.  gen.  de  Med.,  1S64,  37. 

*  Laborde  :  "  De  la  Paralysie  de  I'Enfance."' 

^  Seeligmiiller:  in  Rilliet  et  Barthez,  "  Traite  des  Alal.  de  I'Enfance,"  vol.  ii  ,  p.  551. 

^  M.  P.  Jacobi:    Am.  Journ.  of  Obst.,  May,  1S74. 


544 


ORTHOPEDIC  SURGERY. 


account  of  this  vascular  sluggishness,  ulcers  may  forxTi,  which  are 
slow  to  heal  and  very  painful.  The  limb  even  very  early  loses  its 
normal  appearance,  and  the  flaccid  undeveloped  look  of  the  foot  or 
hand  is  most  noticeable. 

Atrophy  of  the  affected  muscles  begins  to  be  perceptible  a  few 
weeks  after  the  onset  of  the  paralysis,  while  the  loss  of  striation  in 
the  muscular  fibres  can  be  detected  by  the  microscope  within  two 
or  three  days  of  the  attack.'  The  muscles  may  be  tender  to  the 
touch  during  the  time  that  they  are  wasting  so  fast,  especially  in 
adults  and  older  children.  Muscles  seriously  affected  are  toneless 
and  flaccid  from  the  first,  and  in  the  late  stages 
of  wasting  scarcely  any  volume  of  muscle 
seems  left  when  the  limb  is  grasped  with  the 
hand. 

The  paralysis  is  a  purely  motor  one,  and 
although  tingling  and  formication  may  be 
present,  sensation  is  very  rarely  affected.  The 
reflexes  are  abolished  in  the  affected  limb,  the 
slightest  implication  of  the  extensor  muscles 
of  the  thigh  being  enough  to  do  away  with 
the  knee  jerk  of  the  affected  side. 

Sometimes  after  an  attack  the  paralysis 
may  seem  to  be  general,  but  the  probabilities 
are  that  after  improving  in  general  the  loss  of 
power  will  eventually  be  localized  in  one  limb, 
and  that  if  one  limb  originally  is  paralyzed  the  likelihood  is  very 
great  that  a  certain  amount  of  power  will  be  regained,  leaving  only 
certain  groups  of  muscles  permanently  paralyzed. 

The  paralysis  in  its  distribution  is  monoplegic  in  more  than  half 
the  cases,  as  a  consolidation  of  the  tables  of  Duchenne  and  Seelig- 
miiller  will  show. 

One  leg  paralyzed,        ......       74 


Fig.  553. — Muscular  Atrophy 
of  the  Right  Calf  in  Infantile 
Paralysis. 


One  arm         "  ... 

Both  legs,       ''  ... 

Both  arms,     "  ... 

All  four  extremities  paralyzed,    . 

Hemiplegic  paralysis,  . 

Crossed  paralysis. 

Muscles  of  trunk  and  abdomen  paralyzed, 


23 
23 
3 
7 
3 
3 
I 


137 


The  great  preponderance  of  paralysis  of  the  lower  extremities  is 
to  be  noted,  and  the  liability  to  paralysis  increases  even  from  the 
'^  H.  W.  Berg  :    "  Wood's  Ref.  Handbook,"  vol.  v.,  p.   504. 


INFANTILE  SPINAL    J'ANALVS/S. 


545 


thigh  to  the  foot,  and  when  improvement  begins  in  a  case  where 
both  an  upper  and  h)wer  extremity  are  paralyzed,  the  improve- 
ment begins  first  in  the  arm  (Laborde). 

Commonly  certain  groups  of  muscles  are  attacked,  and  where 
adjacent  muscles  are  affected  they  seem  to  be  selected  at  random 
oftener  than  by  functional  association.  In  the  leg,  the  extensors 
and  the  peronei  are  the  muscles  oftenest  affected. 

The  glutei  are  never  affected  alone,  but  they  commonly  share  in 
any  extensive  paralysis  of  the  leg. 

In  the  arm  the  deltoid  suffers  oftener  than  any  other  arm  muscle, 
either  alone  or  in  association  with  other  muscles.  The  "  upper- 
arm  type  "  of  paralysis  which  Erb  has  described, 
consists  of  the  simultaneous  affection  of  the  del- 
toid, supra-  and  infra-spinatus,  the  biceps,  and  the 
supinators. 

There  is  also  a  "  forearm  type "  described  by 
Remak '  in  which,  as  in  lead  paralysis,  the  extensor 
muscles  of  the  hand  are  paralyzed  while  the  supi- 
nator longus  is  spared. 

The  serratus  magnus  is  sometimes  affected  as 
well  as  the  trapezius  and  pectoralis  major. 

The  neck  muscles  are  very  rarely  affected  and 
the  muscles  supplied  by  the  cranial  nerves  almost 
never.  Gowers,  however,  reports  a  case  where 
paralysis  of  one  side  of  the  face  was  associated 
with  paralysis  of  the  limbs. 

The  muscles  of  the  back  may  be  paralyzed  and 
the  patient  be  unable  to  sit  erect,  or  if  the  distri- 
bution of  the  paralysis  is  uneven  lateral  curvature 

1  c  re     •  r  1  ^'''-  5S4- "  Pa^'y^'s 

may  result — a  state  ot  anairs  often  made  worse  of  Left  Arm  Muscles, 
by  allowing  the  patient  to  sit  erect  while  the  mus-     the  Deltoid, and  Serra- 

.  .  .  tus  Magnus. 

cles  are  still  weak.  The  diaphragm  is  occasion- 
ally paralyzed.  In  those  rare  cases  of  paralysis  of  the  abdominal 
muscles,  the  patient  leans  back  to  a  very  marked  degree,  missing 
the  restraining  action  of  those  muscles.  There  are,  finall}-,  cases 
of  universal  paralysis,  wdiere  death  soon  takes  place  from  interfer- 
ence with  respiration. 

The  sequelse  of  the  disease  are  few.  Progressive  muscular  atro- 
phy has  been  several  times  observed  to  start  from  the  diseased 
limb  and  the  symptoms  of  lateral  sclerosis  at  other  times  have 
been  seen  to  develop,-  but  such  occurrences  are  very  rare. 

Deformities. — The  deformities  which  come  on  after  infantile  par- 

'  Remak:    Arch.  f.  Psych.,  Band  ix.,  1878-79,  p.  510. 
-  Gowers:   "  Dis.  of  Nerv.  Syst.,"  vol.  i.,  p.  262. 
35 


546 


OR  THOPEDIC  S  URGER  V. 


alysis  are  late  events  in  the  history  of  the  disease  and  rarely  develop 
until  at  least  some  months  after  the  attack.  They  are,  as  a  rule, 
progressive  in  their  character  and  the  end  results  are  often  such 
extreme  distortions  that  the  affected  limb  is  useless.  The  deform- 
ities fall  into  two  chief  classes:  (i)  deformities  due  to  trophic 
changes,  such  as  bone  shortening,  etc. ;  (2)  deformities  due  to  mus- 
cular paralysis. 

The  first  class  is  comparatively  unimportant;  shortening  of  the 
paralyzed  arm  or  leg  takes  place  and 
atrophy  of  the  bone  in  every  direc- 
tion, so  that  a  liability  to  fracture  is 
of  course  a  necessary  consequence. 
Shortening  of  the  arm  is  compara- 
tively unimportant  in  itself,  but  short- 
ening of  the  leg  is  likely  to  induce  lat- 
eral curvature  of  the  spine  from  the 
necessarily  tilted  position  of  the  pelvis' 
due  to  the  unequal  length  of  the  legs. 


Fig.  555. — Severe  Paralysis  Involving  the  Muscles 
of  the  Back. 


Fig.  556. — Lateral  Curvature  from  Infantile 
Paralysis. 


The  deformities  of  the  second  class,  which  are  the  result  of  mus- 
cular paralysis,  are  manifold  and  form  the  great  bulk  of  the  cases  of 
deformity  in  anterior  poliomyelitis.  As  a  rule  they  do  not  appear 
earlier  than  two  or  three  months  after  the  onset  and  more  com- 
monly not  for  many  months.  Seeligmiiller,  however,  reported  a 
rare  case  where  talipes  equinus  was  noted  in  four  weeks. 

For  clinical  consideration  they  fall  into  two  groups,  deformities 

'  Bradford:  "  Etiology  of  Lateral  Curvature,"  B.  M.  and  S.  J.,  1886,  cxiv. 


INFANTIIJ':  SI'INAL    /'A h'A /.\'S/S.  547 

caused  by  contraction  and  deformities  due  to  laxity  of  the  nuisclcs 
and  ligaments.  Volkmann,  on  the  <j;round  of  I  filter's  investigations, 
would  explain  nearly  all  the  deformities  on  mechanical  grounds, 
urging  that  the  deformities  were  developed  partly  by  reason  of  the 
weight  of  the  limbs  concerned  and  the  position  which  they  assumed 
when  at  rest,  and  partly  because  of  the  muscular  insufficiency  of 
the  affected  limbs  which  allowed  the  articular  surfaces  to  be  sub- 
jected to  an  excessive  pressure  when  brought  into  use,  which  had 
the  effect  of  gradually  pressing  them  into  abnormal  position.  The 
earlier  idea  had  been,  however,  that  they  were  brought  about  by 
the  unopposed  action  of  the  muscles  which  were  not  afTected. 
Probably  both  factors  are  active  in  the  causation  of  deformity. 

A  word  should  be  said  in  regard  to  the  reason  of  the  more  severe 
affection  of  the  anterior  leg  and  thigh  muscles  than  of  the  posterior 
muscles  in  nearly  all  cases.  The  theory  has  been  advanced  that  it 
is  on  this  account  that  after  a  paralysis  of  the  leg,  the  limb  lies  flaccid 
and  nearly  powerless,  the  toes  drop,  and  if  the  sitting  posture  is  as- 
sumed, the  knees  flex  and  hang  heavily  down.  As  a  result  of  this, 
the  anterior  muscles  are  always  pulled  upon  and  slightly  stretched, 
while  the  posterior  ones  are  lax.  If  all  the  muscles  are  equally 
affected,  this  very  factor  may  be  enough  to  make  a  great  difference 
in  the  ultimate  usefulness  of  the  two  groups.  Stretched  muscles 
are  notoriously  at  a  disadvantage,  as  far  as  recovery  goes,  in  any 
diseased  condition,  and  muscles  at  rest  are  much  more  favorably 
situated.  So  that  this  very  point  may  determine  in  a  measure  the 
relative  amount  of  recovery  in  the  two  groups. 

Moreover,  muscular  contraction  and  consequent  deformit}-  only 
occurs  in  cases  where  a  muscle  has  been  allowed  to  remain  for  a 
long  time  in  a  shortened  or  stretched  condition.  For  this  reason, 
it  is  highly  important  to  support  and  restrain  the  affected  limb  in  a 
normal  position  (the  foot  at  a  right  angle  to  the  leg,  etc.).  In  this 
way  alone  may  contraction  deformity  be  prevented. 

The  common  deformities  from  infantile  paralysis  which  come  to 
the  orthopedic  surgeon  for  treatment  are  those  of  the  lower  ex- 
tremity. Considered  in  detail,  it  is  best  to  begin  with  deformities 
at  the  hip-joint  and  then  to  pass  on  to  the  consideration  of  knee- 
joint  deformities  and  distortions  of  the  foot. 

Deformities  of  the  Leg. — Paralysis  maybe  complete  and  a  flail-like 
leg  be  the  result,  with  wasted  muscles,  and  loose  distorted  joints, 
incapable  of  motion  or  bearing  weight.  Such  a  limb  is  spoken  of 
as  "jambe  de  Polichinelle."  Such  a  case  may  be  seen  in  the 
figure  (Fig.  557). 

But  more  commonly  the  paralysis  is  partial  rather  than  complete. 
The  muscles  of  the  thigh  commonly  affected  are  the  internal  and 


545 


OR  THOPEDIC  S  UR  GER  V. 


Fig.  557. — Complete  Paralysis  of  Both  Legs,  showing  Tendency  to  Eversion  and  Abduction. 
The  photograph  was  taken  in  the  Recumbent  position. 


Fig.  558.— Hyperextension  of  the  Knee  following  Infantile  Paralysis. 


INFANT/ L/C  S/'/NA/.    /'A/k'A /,)'S/S. 


549 


anterior  groups.  This  constitutes  ;i  very  scricnis  combination  an.l 
renders  walking  difficult;  not  only  is  the  leg  ahrlucted  with  a  ten- 
dency to  eversion,  but  the  extensor  thigh  muscles  cannot  hold  the 
knee  rigid  as  is  necessary  in  walking,  the  leg  giving  way  whenever 
weight  is  put  upon  it.  The  glutei  are  generally  implicated  in  this 
paralysis,  and  the  contraction  which  is  likely  to  result  from  this 
paralysis  is  flexion  of  the  thigh  alone  or  with  abduction  of  the  !eg, 
a  condition  always  associated  with  flexion  of  the  knee  and  tali[;es 
equino-varus. 

Flexion  deformity  at  the  hip  produces  in  time  a  most  marked 
lordosis  in  the  back.  When  the  patient  stands  with  the  leg  dan- 
gling, the  weight  of  it  drags  upon  tlje  pelvis  and  rotates  it  on  a 
transverse  axis,  a  compensation  which  makes  it  possible  for  the 
leg  to  hang  as  nearly  as  possible  perpendicularly.  This  deformity 
is  most  marked  and  most  troublesome. 

At  the  knee,  contraction  in  the  flexed  position  (with  often  a  ten- 
dency to  subluxation  of  the  tibia  backward)  is  found,  and  in  the 
more  severe  cases  decided  knock-knee.  At  other  times  where 
laxity  rather  than  contraction  predominates,  hyper-extension  of 
the  knee  is  observed  and  sometimes  lateral  mobility  also  exists. 
In  severe  cases  of  this,  where  the  deformity  has  been  rectified  by 
mechanical  or  operative  means,  the  tibia  lies  in  a  plane  decidedly 
posterior  to  that  of  the  femur.  In  the  same  way  with  regard  to 
the  knock-knee  which  results  from  the  greater  prominence  of  the 
internal  condyle  of  the  femur.  The  flexion  may  have  been  over- 
come, but  still  a  decided  degree  of  knock-knee  may  remain  in  the 
corrected  leg. 

Hyper-extension  of  the  knee  may  also  increase  to  a  very  marked 
degree  and  is  commonly  associated  with  talipes  valgus.  This  hy- 
per-extension results  in  cases  where  the  anterior  muscles  are  weak 
and  fail  to  hold  the  knee  stiff  when  walking  is  attempted.  In  these 
cases  the  patient  throws  the  weight  of  the  body  upon  the  fully  ex- 
tended knee  and  the  strain  falls  upon  the  ligaments  rather  than  on 
the  muscles.  The  posterior  ligaments  yield  in  time  to  this  repeated 
weight  and  the  patient  obtains  for  a  time  a  better  bearing.  The 
same  deformity  is  favored  by  a  tendency  which  these  patients  have 
to  lean  with  the  hand  upon  the  knee  when  rising  from  a  chair. 

There  is  a  tendency  to  outward  rotation  of  the  tibia  upon  the 
femur  in  cases  of  long-standing  paralysis  of  the  leg.  In  this  cases 
the  eversion  of  the  foot  in  walking  is  a  troublesome  complication. 

Inasmuch  as  paralyses  of  the  anterior  tibial  muscles  and  the 
peronei  are  the  most  frequent,  the  deformities  that  one  sees  often- 
est  are  talipes  equino-varus,  or,  if  the  peronei  are  intact,  talipes 
equinus.     Pure  talipes  varus  from  this  cause  is  not  common,  even 


550 


ORTHOPEDIC  SURGERY. 


if  all  the  muscles  of  the  leg  are  paralyzed  alike,  the  occurrence  of 
talipes  equino-varus  is  favored  by  gravity.  The  toes  drop  as  the 
patient  lies  in  bed  and  the  added  weight  of  the  bedclothes  acts  in 
the  same  direction.  Under  these  circumstances  it  is  not  strange 
that  talipes  equino-varus  is  the  commonest  deformity  of  the  foot 
after  infantile  paralysis.' 


Fig.  56o.--Flaccid  Limb  and 
Extended  Foot  from  Complete 
Infantile  Paralysis  of  the  Leg. 


Fig.  561. — Dropping 
of  Foot  in  Infantile 
Paralysis. 


Fig.  55Q. — Wasting  of  Right  Leg  after 
Infantile  Paralysis  with  Development  of 
Talipes  Equino- Varus. 


Fig.  562. — Talipes  Varus  Due  to  Infantile 
Paralysis. 


It  will  be  seen  that  hyper-extension  of  the  knee  is  favored  in 
cases  where  talipes  equinus  exists,  as  by  that  means  alone  the  foot 
can  be  placed  fiat  on  the  ground. 

Talipes  calcaneo-valgus  and  pure  flat-foot  are  favored  by  lax 
ligaments,  and   the  latter   may  be   a  progressive  deformity,  which 

'  Ross:    "  Dis.  of  Nerv.  Syst. ,"  Wm.  Wood  &  Co.,  1878,  p.  942. 


INFANT/ IJC  SI'JNAL   J' ARAL  YSIS. 


551 


increases  until  a  staj^^c  is  readied  where  the  inner  malleolus  ahnost 
touches  the  ground  and  the  foot  can  be  flexed  until  the  dorsum 
touches  the  skin  over  the  tibia.  The  bearinj^  of  body  weight  on  a 
foot,  the  ligaments  and  muscles  of  which  are  weak,  tends  to  j)ro- 
duce  fiat-foot. 

Pure  talipes  calcaneus  seems  the  result  of  the  i)aralysis  of  the 
posterior  calf  muscles  combined  with  the  action  of  gravity  and 
superincumbent  weight.  What  is  known  as  pes  cavum  is  more 
common  than  pure  talipes  calcaneus. 

The  order  of  frequency  of  the  different  forms  of  deformity  from 
anterior   poliomyelitis    is    as    follows:    (i)    talipes    equino- 
varus;    (2)   calcaneo-valgus;    (3)  equinus;  (4)   calcaneus   or 
pes  cavum. 


Fig.  563.  Fig.  564. 

Figs.  563,  564. — Talipes  Calcaneus  and  Pes  Cavum. 

Deformities  of  the  arms  are  comparatively  uncommon  as  the  re- 
sult of  Infantile  paralysis.  The  least  infrequent  of  these,  results  from 
the  paralysis  of  the  deltoid.  In  addition  to  the  inability  to  raise 
the  arm  from  the  side,  there  is  a  flattening  of  the  shoulder  and  a 
prominence  of  the  acromion  process,  and  the  shoulder  presents  an 
angular  rather  than  a  rounded  outline.  The  ligaments  are  loosened, 
and  the  arm  hangs  loosely,  so  that  in  some  cases  a  wide  gap  may. 
be  observed  between  the  acromion  and  the  humerus. 

Any  distortion  of  the  arm  and  hand  further  than  the  fiaccid  con- 
dition resulting  from  the  paralysis,  is  quite  rare.  If  contraction 
does  occur,  it  follows  the  type  to  be  seen  in  adult  hemiplegia:  flex- 
ion of  the  elbow,  hand,  and  fingers. 

The  commonest  paralysis  of  the  hand  is  one  affecting  the  adduc- 
tor muscles  of  the  thumb,  as  a  result  of  which  the  thumb  is  drawn 
back  to  a  level  with  the  other  fingers-  and  the  power  to  oppose  it 


552  ORTHOPEDIC  SURGERY. 

to  the  other  fingers  in  grasping  is  thus  lost.  Flexion  of  the  hand 
and  fingers  may  be  observed,  or  flexion  of  the  hand  with  some 
mobility  of  the  fingers.  The  distortion  may  be  severe  enough  to 
constitute  what  has  been  termed  a  club-hand. 

Infantile  paralysis  of  the  sterno-mastoid  muscle  is  recognized  as 
an  occasional  cause  of  wry  neck.  Paralysis  of  the  intercostal  mus- 
cles rarely  causes  deformity,  but  Gowers  saw  a  case  where  a  per- 
manent depression  in  one  side  of  the  thorax  resulted  from  such  a 
paralysis. 

Paralysis  of  the  erector  spinae  muscles  results  in  a  permanent 
arching  of  the  spine  and  inability  to  sit  erect. 

Paralysis  of  the  abdominal  muscles  causes  lordosis. 

Lateral  curvature  of  the  spine  results  from  infantile  paralysis  in 
one  of  three  ways. 

(i.)  From  the  inequality  in  the  length  of  the  legs  (due  to  paral- 
ysis of  one  leg)  causing  tilting  of  the  pelvis.  (2.)  From  the  uni- 
lateral paralysis  of  the  muscles  directly  controlling  the  vertebral 
column  which  might  be  either  a  paralysis  of  the  intrinsic  spinal 
muscles  or  of  the  erector  spinae  group  on  one  side.  (3.)  From 
faulty  spinal  attitudes  assumed  in  consequence  of  some  paralysis 
elsewhere,  as  in  paralysis  of  one  arm,  or  of  the  serratus  magnus,  or 
even  of  the  sterno-mastoid.  These  cases  have  been  more  particu- 
larly considered  under  the  head  of  lateral  curvature. 

Dislocations  froin  Infantile  Paralysis. — Dislocation,  complete  or 
partial,  is  not  very  rare  in  the  joints  of  an  affected  limb,  although 
it  belongs  to  the  more  uncommon  of  the  complications  of  infantile 
paralysis  and  characterizes  severe  cases. 

Dislocation  of  the  hips  is  by  all  means  the  one  most  commonly 
met  and  it  takes  place  either  spontaneously  or  in  consequence  of 
weight  being  borne  upon  a  limb  which  is  improperly  supported  by 
its  ligaments.  It  occurs  only  in  cases  where  the  paralysis  is  severe 
and  of  long  standing,  and  it  at  once  disables  the  leg  on  account  of 
the  laxity  with  which  the  femur  articulates  with  the  pelvis.  A 
shortening  of  one  or  two  inches  may  be  present,  as  the  dislocation 
is  generally  on  to  the  dorsum  of  the  ilium,  but  sometimes  it  takes 
the  form  of  a  laxity  of  the  joint  in  all  directions,  so  that  the  head 
may  be  thrown  into  any  position  by  manipulation  of  the  shaft. 
Such  a  case  is  shown  in  the  figure  (Fig.  565).  The  boy  walks  with 
surprisingly  little  disability  with  the  head  of  the  femur  playing  up 
and  down  the  dorsum  of  the  ilium.  Most  dislocations  of  the  hip  are 
inconvenient  chiefly  because  of  the  shortening  and  insecurity  which 
follow  the  displacement  of  the  head  of  the  bone.  But  the  head  of 
the  bone  in  a  year  or  two  becomes  often  quite  firmly  fixed  in  its 
new  position  and  such  legs  are  sometimes  nearly  as  serviceable,  as 


INFANTILIC  Sr/NAf.    /'ANALYSIS. 


f  f  9 


they  were  before.  Dislocation  may,  however,  occur  before  any 
weight  is  borne  upon  the  affected  hmb,  by  the  spontaneous  action 
of  the  muscles,  as  in  a  case  eighteen  months  old  in  the  experi- 
ence of  the  writer,  where  dislocation  of  one  hip  took  place  at  the 
age  of  three   months.     In   this  case  the   dislocation  was  reduced 


m 


'sm 


vi:-''-if  f&> 


Fig.  565. — Dislocation  of  Hip,  the  Result  of  Infantile  Paralysis.     In  this  position  the  head  of  the  femur  is 
in  the  acetabulum,  but  when  the  legs  are  made  parallel  the  dislocation  returns. 

under  an  anaesthetic,  and  by  the  application  of  a  plaster-of-Paris 
bandage  the  head  of  the  femur  w^as  permanently  retained  in  the 
acetabulum. 

These  dislocations  are  rarely  attended  by  much  pain  and  are 
often  overlooked  by  the  parents. 

Laxity  of  the  knee-joint,  so  that  the  joint  surfaces  slip  by  each 
other  in  the  motions  of  the  joint,  is  a  less  common  affection,  but  is 


554  ORTHOPEDIC  SURGERY. 

sometimes  seen.     In  these   cases  the  joint  is  subluxated  at  each 
step. 

The  subluxation  of  the  tibia  in  severe  cases  of  knee  flexion  and 
the  dislocation  of  the  shoulder  after  paralysis  of  the  deltoid  muscle 
have  been  already  mentioned. 

Diagnosis. 

In  typical  cases  the  diagnosis  of  infantile  paralysis  is  not  difficult. 
But  in  other  than  typical  cases  the  recognition  of  the  disease  may 
be  extremely  difficult,  and  it  is  never  easy  to  establish  a  positive 
diagnosis  in  the  initial  stage.  At  that  time  the  occurrence  of  local- 
ized pain  is  a  misleading  symptom,  and  sensitiveness  of  the  affected 
limbs  may  suggest  rheumatism.  The  occurrence  of  convulsions 
and  unconsciousness  may  divert  the  attention  to  the  brain,  and  all 
sorts  of  side  issues  may  be  suggested  by  the  manifold  symptoms  of 
the  onset  of  the  disease.  The  affection  is  often  wrongly  classed  as 
cerebro-spinal  meningitis  at  the  earliest  stage,  as  the  head  is 
sometimes  drawn  backward  in  severe  cases. 

The  diagnostic  points  upon  which  the  general  practitioner  must 
rely  are  the  sudden  onset,  a  motor  paralysis,  rapid  muscular  wast- 
ing, the  distribution  of  the  paralysis  (mostly  monoplegic  and  very 
rarely  hemiplegic),  and  the  loss  of  the  tendon  reflex.  Diagnosis  by 
the  determination  of  the  electrical  reaction  of  the  muscles  requires 
especial  training  and  skill,  although  it  is  distinctive  and  the  most 
reliable  test  at  our  command. 

Electrical  Condition  of  the  Muscles. — The  electrical  reactions  in 
infantile  paralysis  are,  however,  clearly  marked  and  characteristic 
when  they  can  be  obtained.  Faradic  irritability  of  the  affected 
muscles  and  nerves  begins  to  diminish  within  a  day  or  two  of  the 
onset  of  the  paralysis,  and  in  muscles  severely  affected  the  electric 
irritability  disappears  entirely;  in  the  muscles  less  seriously  in- 
volved it  is  merely  diminished.  This  constitutes  a  valuable  symp- 
tom in  prognosis,  as  in  muscles  which  are  completely  paralyzed 
faradic  irritability  is  permanently  lost  by  the  second  iveek.  But  even 
in  later  years  it  is  possible  to  find  in  such  muscles  a  trace  of 
irritability  to  the  faradic  current,  as  demonstrated  in  his  lectures 
by  Dr.  E.  C.  Seguin,  who  thrusts  a  hypodermic  needle  into  the 
muscular  substance  and  transmits  the  current  through  that  shows 
that  the  muscle  contracts.  But  the  change  in  reaction  to  the 
galvanic  current  is  even  more  important.  Normally  when  this 
current  is  passed  through  nerve  and  muscle,  a  quick  sharp  muscu- 
lar contraction  takes  place  at  the  opening  and  closing  of  the  cur- 
rent and  the  muscular  contraction  should  be  greater  at  the  closing 


INFANTJU'l  Sr/NAL    J'AKALVSIS.  555 

of  the  negative  pf)le  than  wlicn  tlic-  positive  pole  is  closed.  Tech- 
nically it  is  expressed  thus:  the  catluKJal  closing  contraction  is 
greater  than  the  anodal  closing  contraction,  or  K.C.C.  >  A.C.C. 
(The  relation  of  the  opening  contractions  is  exj^ressed  by  the  for- 
mula A.O.C.  >  K.O.C.,  but  it  is  of  less  importance.)  When  nerves 
and  muscles  affected  by  anterior  jjoliomyelitis  are  examined,  not 
only  a  slow  wave-like  response  to  electricity  instead  of  a  sharp 
quick  jerk  is  found,  but  the  electrical  formula  is  reversed  and  the 
closure  of  the  positive  pole  gives  the  greater  contraction.  More  exactly 
K.C.C.  <  A.C.C,  or  K.C.C.  =  A.C.C.  (the  contraction  on  opening 
the  current  is  also  reversed).  In  general  a  much  stronger  galvanic 
current  is  needed  to  produce  a  contraction  in  these  paralyzed  mus- 
cles than  in  normal  ones.  These  qualitative  and  quantitative 
changes  in  reaction  to  the  galvanic  current  constitute  what  is 
known  as  the  "  reaction  of  degeneration,"  and  this  afforde  the  most 
definite  ground  for  the  diagnosis  of  infantile  paralysis.  But  such 
an  examination  to  be  of  any  value  requires  a  great  deal  of  practice 
and  special  skill  in  the  use  of  electricity.  In  young  children  the 
examination  often  yields  no  results  even  to  a  specialist  in  nervous 
diseases  on  account  of  the  child's  constant  activity,  and  although 
it  is  the  most  definite  means  of  diagnosis  that  we  possess  in  obscure 
cases,  its  use  is  attended  with  many  difficulties. 

The  only  affection  which  may  not  be  distinguished  by  electrical 
examination  from  anterior  poliomyelitis  is  peripheral  paralysis 
caused  by  interruption  in  the  course  of  some  nerve. 

Differential  Diagnosis. 

The  leading  points  which  are  to  be  depended  upon  in  the  differ- 
ential diagnosis  are  these:  Infantile  paralysis  is  purely  a  motor 
affection  and  sensation  is  never  permanently  impaired.  The  re- 
flexes are  diminished  or  lost.  Wasting  is  rapid  and  extreme  and 
the  leg  is  cold  and  blue  in  severe  cases.  The  "  reaction  of  degen- 
eration "  is  present  in  electrical  examination. 

Cerebral  paralysis  g&nerBWyhe^xns  with,  a  sudden  onset,  and  often 
convulsions  are  present  and  the  child  is  found  to  have  lost  the  use 
of  one  side  of  the  body.  It  differs  from  infantile  paralysis  in  these 
points :  Its  distribution  is  hemiplegic  and  facial  paralysis  is  com- 
mon, the  tendon  reflexes  are  increased  from  first  to  last,  faradic 
excitability  is  not  lost,  and  the  galvanic  formula  is  normal;  later 
the  intelligence  is  generally  affected  and  atrophy  is  neither  so 
marked  nor  so  rapid  as  in  infantile  spinal  paralysis,  but  similar  con- 
tractions of  the  joints  of  the  affected  limb  come  on.  These  con- 
tractions are,  however,  often  spastic  in  character.     Allusion  must 


556 


ORTHOPEDIC  SURGERY. 


be  made  to  the  importance  of  electricity  in  making  a  differential 
diagnosis,  which  is  often  attended  with  much  difficulty.  A  hemi- 
plegic  distribution  of  infantile  spinal  paralysis  is  not  very  rare '  and 
cases  have  been  reported  when  the  facial  nerve  was  involved.^ 

Table  of  the  Differential  Diagnosis  of  Infantile  Paralysis  and 
Cerebral  Paralysis. 

Cerebral  Paralysis  (Hemiplegia). 

Not  sharply  limited  to  young 
children. 

Sudden,  and  severe  convul- 
sions generally  present. 

Hemiplegia ;  generally  involv- 
ing facial  muscles  on  one 
side. 

Increased. 

Faradism  normal. 

Galvanism  normal. 


Infantile  Spinal  Paralysis. 

Age. 

Sharply  limited  to  children  in 

first  dentition. 

Onset. 

Sudden,   but    severe    convul- 

sions not  often  present. 

Distribution  of 

Oftenest  monoplegia  or  para- 

paralysis. 

plegia;  never  involves  facial 

nerve. 

Reflexes. 

Lost. 

Electrical     reac- 

Faradism diminished  or  lost. 

tion. 

Galvanism   formula    reversed 

(reaction  of  degeneration). 

Mental  Impair- 

Absent. 

ment. 

Spastic  conditions  absent. 


Likely  to  come  on. 

Spastic  condition  of   one  or 
both  legs  often  follows. 


Both  affections  are  characterized  by  motor  paralysis,  wasting  and 
retarded  growth  of  the  affected  limb,  and  contractions  of  the 
joints. 

Progressive  imisadar  atrophy  in  childhood  is  a  very  rare  affection, 
but  it  has  been  observed,  sometimes  beginning  in  the  legs.  Its 
onset  is  gradual,  and  the  faradic  excitability  remains  as  long  as 
there  is  any  muscular  substance  left  and  the  galvanic  formula  re- 
mains normal.  The  reflexes  are  not  lost  until  all  muscular  sub- 
stance has  gone. 

Acute  transverse  myelitis  of  the  dorsal  region  causes  paralysis  of 
the  legs  when  it  occurs  (and  it  is  very  rare  in  children),  but  unless 
the  lumbar  enlargement  is  involved  there  is  no  loss  of  electrical 
irritability.  Reflex  action  after  a  day  or  two  is  much  increased 
and  ankle  clonus  can  be  obtained.  There  is  generally  paralysis  of 
sensation,  and  bed-sores  develop  with  much  rapidity,  while  any 
wasting  is  very  gradual.  There  is  no  change  in  the  electrical 
formula. 

In  extensive  spinal  hemorrhage  paralysis  is  complete  and  affects 
both  sensation  and  motion.  Bed-sores  soon  form  and  reflexes  are 
much  increased. 

'  Duchenne  and  Seeligmiilier  (3  cases),  Sinkler  (4),  West  (5),  Heine  (i),  Leyden  (i), 
Duchenne  (i). 

^  Henoch:   Loc.  cit.,  p.  203;    Barlow:    Loc.  cit.,  p.  76;   Seeligmiilier. 


IN/'AiYT/fJC  Sl'JA'AL   J'ARALYSIS.  557 

DipJitJicritic  paralysis  m.'iy  offer  serious  (lifficiilty  in  flia^nosis,  be- 
cause anterior  polio-myelitis  may  occur  in  the  c(jurse  of  a  diijhtheritic 
attack  as  in  any  other  infectious  disease.  The  paralysis  of  dipiitheria 
affects  oftenest  the  muscles  of  the  palate  and  fauces,  the  electrical 
reactions  remain  normal,  and  severe  atrophy  is  not  present. 

Pscudo-Jiypcrtrophic paralysis  in  its  early  stages  is  nrjt  likely  to  be 
confused  with  infantile  paralysis,  for  it  is  generally  characterized 
by  much  increase  in  the  size  of  the  muscles,  which  is  extensively 
distributed  and  comes  on  very  gradually  and  is  not  accompanied 
by  any  marked  electrical  changes. 

Late  in  the  affection  marked  muscular  atroply  occurs,  but  it  is 
generalized  and  the  history  would  clearly  differentiate  the  condition 
from  anterior  poliomyelitis. 

Paralysis  may  result  from  lesion  of  a  peripheric  nerve,  as  in  in- 
strumental delivery  at  childbirth,  from  tight  bandaging,  etc.  liut 
its  distribution  is  limited  to  a  single  nerve  and  it  is  characterized 
by  a  concomitant  affection  of  sensibility.  The  electrical  reaction 
would  be  the  same  as  in  infantile  paralysis. 

The  so-called  rhachitic  paralysis  might  offer  some  difficulty  of 
diagnosis.  But  it  occurs  in  the  acute  stage  of  rickets  and  is  not  a 
paralysis  so  much  as  a  disinclination  to  use  weak  and  sore  limbs. 
It  is  accompanied  by  general  tenderness,  and  to  a  certain  extent 
the  diagnostic  signs  of  rickets,  the  reflexes  are  normal  and  its  onset 
is  more  graduak  It  is,  however,  so  early  a  complication  of  rickets 
that  its  recognition  may  offer  much  difficulty. 

Practically  infantile  paralysis  of  one  leg  sometimes  simulates  at 
first  sight  congenital  dislocation  of  the  hip,  but  only  inattention 
can  account  for  a  mistake  in  the  diagnosis.  In  congenital  disloca- 
tion the  trochanter  would  be  above  Nelaton's  line,  it  would  \-ield 
to  traction,  atrophy  would  be  very  slight,  and  the  electrical  reac- 
tion normal. 

With  hip  disease,  infantile  paralysis  is  at  times  confounded  in 
practice.  The  onset  of  the  paralysis  may  be  accompanied  by  joint 
pain  and  tenderness,  and  on  the  other  hand  hip  disease  is  accom- 
panied by  serious  muscular  atrophy  and  a  modification  of  faradic 
irritability  of  the  muscles,  as  Shaffer'  has  shown.  But  the  distin-- 
guishing  feature  of  hip  disease  is  muscular  fixation,  and  that  is  not 
present  in  infantile  paralysis,  where  muscular  laxity  is  the  prevail- 
ing condition.  The  onset  of  hip  disease,  although  generally  grad- 
ual, may  at  times  be  apparently  sudden. 

One   other  affection  is  often   confused  with  infantile  paralysis; 
this  is  cerebro-spinal  meningitis,  and  at  the  onset  a  positive  distinc- 
tion is  almost  impossible.     But  cerebro-spinal  meningitis  is  a  much 
'  N.  M.  Shaffer:    Archives  of  Medicine,  New  York. 


558  ORTHOPEDIC  SURGERY. 

more  grave  disease,  and  goes  on  without  improvement.  Retraction 
of  the  head  is  very  marked  and  pain  and  convulsions  are  prominent 
symptoms.  It  is  not,  however,  followed  by  permanent  paralysis, 
and  cannot  be  assumed  as  the  cause  of  infantile  paralysis,  as  in 
practice  is  not  uncommonly  done. 

Prognosis. 

So  far  as  danger  to  life  is  concerned,  the  outlook  in  infantile 
paralysis  is  very  favorable,  for  few  patients  die  in  the  acute  attack. 
When  death  does  occur  it  is  generally  at  the  end  of  a  week  or  ten 
days,  from  interference  with  respiration,  and  this  would  only  occur 
in  very  extensive  paralysis.  Continued  cerebral  symptoms,  how- 
ever, are  of  very  grave  significance.  In  cases  where  the  deformity 
is  only  of  moderate  extent,  it  is  not  probable  that  life  will  be  short- 
ened by  it. 

It  is  not  likely  that  the  paralysis  will  increase  any  more  when  it 
has  been  stationary  for  twenty-four  hours.  Second  a4:tacks  are 
very  rare,  and  when  they  do  occur,  they  come  on  within  a  day  or 
two  of  the  original  attack  and  are  made  evident  by  an  increase  of 
the  existing  paralysis. 

The  tendency  of  the  paralysis,  as  we  have  seen,  is  toward  im- 
provement and  partial  recovery.  The  law  of  Duchenne  gives  the 
key-note  to  a  more  exact  prognosis  in  establishing  the  fact  that 
all  the  paralyzed  muscles  in  which  the  faradic  irritability  is  only 
more  or  less  diminished,  but  not  completely  lost,  during  the  course 
of  the  second  week,  do  not  remain  permanently  paralyzed,  the 
restoration  being  more  prompt  and  complete  the  less  their  faradic 
irritability  has  been  diminished.  In  general  v^hen  the  faradic  irri- 
tability is  lost  at  once,  paralysis  will  be  severe  and  to  a  certain  ex- 
tent permanent.  When  the  irritability  is  lost  later,  the  paralyzed 
muscles  will  improve  slowly  and  nearly  recover.  When  faradic 
irritability  is  not  lost  at  all,  recovery  will  take  place  in  a  few  weeks 
or  months.  Without  the  use  of  electricity  one  has  to  wait  much 
longer  before  giving  any  more  definite  prognosis  than  a  general 
promise  of  improvement. 

When  untreated,  a  case  of  infantile  paralysis  will  almost  invaria- 
bly improve  for  one  or  two  months  at  a  rapid  rate,  then  more 
slowly  for  two  or  three  months  more,  and  then  after  a  stationary 
period  contractions,  looseness  of  the  joints,  and  malpositions  will 
begin  to  be  evident,  which  may  increase  indefinitely.  Under 
treatment  the  prognosis  is  much  more  favorable  and  the  limit  of 
possible  improvement  extended  by  several  years.  There  is  scarcely 
any  leg,  however  wasted 'and  contracted,  that  is  not  amenable  tO' 
improvement  by  operative  or  mechanical  treatment. 


INFANT// JC  SI'INAL    I' A h'.l /.YS/S. 


559 


It  should  be  rcmciiibcrcd  that  even  in  mild  c.ises  of  infantile 
paralysis  bone  shortening  is  liable  to  follow.  It  is  a  very  variable 
thing,  and  certain  severe  cases  escape  with  but  little,  while  a  mild 
case  of  talipes  valgus  may  show,  witli  the  wasting  of  the  leg,  a 
shortening  of  one  or  two  inclics  in  the  limb  of  the  affected  side,  or 
in  exceptionally  severe  cases,  sh(jrtening  of  several  inches. 

Treatment. 

The  treatment  of  infantile  paralysis  varies  according  to  the  stage 
at  which  treatment  is  to  be  undertaken. 

Tlie  Stage  of  Onset. — If  the  fact  that  paralysis  is  present  is  estab- 
lished during  the  febrile  attack,  which  is  usually  the  first  symptom 
of  the  disease,  vigorous  treatment  should  be  at  once  begun,  to  limit, 
if  possible,  the  destructive  process  in  the  cord.  Cathartics  should 
be  given  at  once,  the  patient  should  lie  on  the  side  or  the  belly,  to 
prevent  stasis  of  the  blood  in  the  spinal  cord,  and  counter-irritants 
or  cups  should  be  applied  over  the  spine.  The  application  of  ice 
bags  to  the  back  or  cold  compresses  is  advocated  in  this  as  in 
nearly  all  spinal  affections. 

Certain  drugs  exert,  it  is  thought,  an  influence  upon  this  stage  of 
the  disease.  Ergot  freely  administered  is  recommended  by  Ham- 
mond in  doses  of  ten  drops  of  the  f^uid  extract,  three  times  a  day, 
for  infants  of  six  months,  and  half  a  drachm  for  children  of  one  or 
two  years,  while  Daly  and  Althaus  would  give  the  drug  subcuta- 
neously.  Belladonna  or  atropine  is  borne  well  by  children  and  is 
much  advocated  for  use  in  this  affection ;  it  should  be  given  in 
large  doses.  Mercurial  inunctions  and  hydrargyrum  cum  creta 
have  both  been  largely  employed,  as  has  also  iodide  of  potassium, 
but  the  present  tendency  is  rather  away  from  the  use  of  these 
drugs.  Strychnine  is  a  remedy  much  depended  upon  in  the  stage 
of  recovery,  and  it  is  probably  of  benefit,  but  it  should  not  be  used 
until  the  signs  of  the  initial  irritation  have  disappeared,  as  the  drug 
undoubtedly  leads  to  activity  and  consequent  irritation  of  the 
spinal  motor  centres.  It  is  sometimes  used  subcutaneously  and  in- 
jected into  the  affected  muscle,  a  method  physiologically  absurd 
and  attended  with  some  little  risk  of  abscess. 

Nitrate  of  silver  in  one-eighth  grain  doses  has  been  also  advised. 
Bromide  of  potassium  and  of  sodium  are  recommended  on  the 
ground  that  they  contract  the  capillaries  of  the  spinal  cord.  The 
benefit  from  the  administration  of  these  drugs  has  not  as  yet  been 
demonstrated. 

In  short,  during  the  onset  every  measure  should  be  directed  to 
drawing  blood  from  the  cord  and  quieting  so  far  as  possible  the 
general  circulation. 


560  ORTHOPEDIC  SURGERY. 

The  Stage  of  Paralysis. — But  few  cases  are  seen  by  the  physician 
until  the  stage  of  paralysis  is  present,  when  treatment  by  medicine 
is  manifestly  of  little  avail.  The  question  that  then  presents  itself 
is  in  regard  to  the  treatment  of  the  paralysis,  in  order  that  the 
ultimate  amount  of  muscular  power  may  be  as  great  as  possible. 
It  must  be  remembered  that  the  tendency  of  the  paralysis  is  at  first 
very  strong  toward  spontaneous  improvement.  It  is,  therefore, 
manifest  that  in  the  first  few  weeks  treatment  should  be  directed 
toward  producing  conditions  which  shall  be  as  favorable  as  possible 
for  that  improvement  to  attain  its  maximum. 

The  object  of  treatment  in  this  stage  should  therefore  be  first  to 
support  the  affected  limb  in  a  normal  position,  and  most  carefully 
guard  against  the  stretching  of  joints  and  ligaments  and  muscles; 
and,  secondly,  by  the  use  of  electricity,  massage,  and  systematic 
exercise  to  keep  the  nutrition  of  the  affected  muscles  in  the  best 
possible  condition.  This  may  be  termed  protective  treatment.  In 
this  way  only,  by  beginning  the  treatment  at  the  first,  can  the  best 
possible  ultimate  result  be  obtained.  These  methods  are  probably 
aided  by  active  medication  during  the  onset  of  the  disease  and 
during  the  course  of  the  paralysis  by  the  administration  of  strych- 
nine, or  bromides,  or  ergot,  if  it  is  supposed  that  any  active  conges- 
tion of  the  cord  remains. 

It  has  been  seen  that  what  should  be  called  protective  treatment 
should  be  begun  at  once,  and  from  the  first  the  diseased  limb 
should  be  placed  and  retained  in  a  normal  position,  so  that  the 
alTected  muscles  and  joints  may  be  supported  and  kept  at  rest.  In 
this  way  the  enfeebled  muscles  are  placed  under  the  best  possible 
conditions  for  their  recovery.  To  allow  attention  to  be  diverted 
from  these  very  important  measures  to  pursue  a  medical  treatment 
whose  utility  is  doubtful,  is  manifestly  irrational.  It  must  be  re- 
peated here  that  the  muscles  do  not  contract  and  deformities  do 
not  come  on  in  properly  supported  limbs. 

In  paralysis  of  the  legs  the  feet  should  be  supported  at  a  right 
angle,  in  their  normal  position,  by  some  simple  splint  or  similar 
appliance,  and  the  weight  of  the  bed  clothes  should  be  kept  off  of 
the  toes.  If  this  is  neglected,  a  very  troublesome  deformity  is 
allowed  to  develop,  which  might  have  been  entirely  avoided  by  a 
little  care. 

The  appliances  needed  to  maintain  in  a  proper  position  the  limbs 
of  a  patient  with  paralysis  will  vary  according  to  the  parts  affected 
and  will  demand  some  ingenuity  on  the  part  of  the  surgeon.  In 
severe  and  extensive  cases  a  wire  cuirass,  such  as  is  used  in  hip  dis- 
ease, can  be  employed  at  times  in  cases  of  young  children,  or  light 
bed-frames  may  be  very  useful  to  allow  the   patient  to  be  carried 


INFANT/fJC  SJ'JNAL    J'A J</1  LYSIS.  561 

about,  while  retainiiitj  the  limbs  in  a  proper  f;osition.  As  far  as 
possible  in  such  cases  bandages  should  be  avoided,  and  straps 
should  be  used  instead,  as  the  surface  circulation  is  feeble  and  likely 
to  be  impeded  by  bandages. 

When  the  arm  is  paralyzed,  a  slinj^  should  be  worn  to  prevent 
dragging  of  the  arm  upon  the  shoulder-joint  ligaments  and  the 
weakened  deltoid  muscle. 

Observance  of  extreme  care  in  these  early  stages  of  the  disease 
to  protect  the  joints  of  the  paralyzed  limb  is  one  of  the  strongest 
elements  of  success  in  the  treatment  of  the  affection.  So  long  as 
the  patient  is  in  bed,  the  use  of  other  apparatus  than  the  simple 
supporting  measures  above  mentioned  is  not  indicated,  and  the 
simplest  contrivances,  such  as  sand  bags,  pillows,  and  the  like  arc 
enough  to  keep  the  limbs  in  normal  positions. 

All  authors  agree  that  electricity,  is  a  most  useful  therapeutic 
measure  in  the  early  stages  of  the  paralysis.  Treatment  should  be 
begun  as  early  as  the  spinal  irritation  seems  to  have  disappeared, 
probably  about  the  end  of  the  first  week,  and  continued  indefi- 
nitely. The  galvanic  current  is  used,  and  with  one  electrode  ap- 
plied over  the  spine,  a  very  gentle  current  is  passed  through  the 
affected  muscles  and  nerves  for  a  few  minutes  each  day,  and  mus- 
cles which  contract  only  feebly  to  faradism  should  be  daily  stimu- 
lated by  the  application  of  the  faradic  current.  Muscles  which  will 
not  contract  to  faradism  can  sometimes  be  much  improved  by 
applications  of  the  interrupted  galvanic  current.  Probably  elec- 
trical treatment  receives  much  credit  in  the  treatment  of  this  dis- 
ease, which  is  not  properly  due  to  it,  for  it  is  employed  at  a  time 
when  marked  improvement  is  almost  certain  and  very  much  the 
same  results  can  be  obtained  by  methods  about  to  be  considered. 
Even  the  warmest  advocates  of  electricity  admit  that  its  results 
"  are  not  precisely  brilliant  "  (Erb),  and  every  one  sees  cases  where 
it  has  ceased  to  benefit  the  child  and  has  been  persisted  in  to  the 
exclusion  of  more  rational  treatment  for  that  especial  case.  But 
even  in  the  late  stages  of  the  disease,  when  wasting  and  deformity 
have  come  on,  the  use  of  electricity  may  at  times  lead  to  a  decided 
improvement  of  nutrition. 

Dry  warmth  and  rubbing  are  measures  which  seem  of  equal,  if 
not  of  greater,  value  in  the  stage  of  simple  paralysis.  They  possess 
the  advantage  of  being  within  the  reach  of  every  one  and  are  much 
more  likely  to  be  efficiently  carried  out  than  electrical  treatment. 
Heat  is  easily  applied  by  having  the  child  sit  in  front  of  a  fire  or 
stove  with  the  leg  thrust  through  a  hole  in  a  sheet  of  pasteboard. 
This  serves  as  a  screen  to  the  rest  of  the  body,  while  the  affected 
member  is  allowed  to  become  thoroughly  warmed  once  or  twice  a 
36 


562 


ORTHOPEDIC  SURGERY. 


day.  During  the  day,  especially  in  cold  weather,  the  paralyzed 
limb  should  be  protected  by  two  thick  stockings  and  a  warm  boot. 
Heat  can  be  applied  to  the  diseased  limb  by  means  of  the  warm 
bath  also,  but  that  induces  sensitiveness  of  the  skin  and  can- 
not be  used  so  often  as  the  dry  heat.  Another  method  of  baking 
the  limb  is  to  have  a  right-angled  stove  funnel  inserted  into  a 
wooden  or  tin  box  which  is  provided  with  a  hole  just  large  enough 
to  admit  the  paralyzed  limb,  then  by  setting  a  lamp  under  the  fun- 
nel the  temperature  in  the  box  can  be  raised  to  any  desired  height. 
Any  treatment  which  stimulates  the  circulation  of  the  paralyzed 
limb  aids  in  its  recovery  by  improving  the  nutrition  of  the  muscles, 
and  dry  heat  very  effectually  accomplishes  this  end.  A  paralyzed 
leg  should  be  thoroughly  heated  for  an  hour  before  it  is  rubbed  at 
night. 

Rubbing  or  massage  is  another  most  important  method  of  treat- 
ment in  this  as  in  any  stage  of  infantile  paralysis  after  the  initial 
irritation  has  quieted  down.  Skilled  massage,  when  it  can  be  ob- 
tained, is  of  course  better  than  friction  at  the  hands  of  the  parents, 
but  the  latter  is  a  simple  and  eilticient  treatment,  which  lies  within 
the  reach  of  every  one,  whereas  massage  entails  a  serious  expense. 
Any  parent  of  average  intelligence  can  be  taught  to  rub  efficiently, 
and  in  this  way  a  most  valuable  means  of  treatment  is  brought 
within  the  reach  of  nearly  every  one. 

The  paralyzed  limb,  after  being  thoroughly  warmed,  is  held  in 
one  hand  and  first  briskly  rubbed  with  the  palm  of  the  other  hand, 
which  with  light  quick  strokes  rubs  from  the  toes  toward  the  centre 
of  the  body.  The  whole  surface  of  the  paralyzed  limb  should  be 
gone  over  in  this  way,  beginning  with  the  foot  and  then  taking  in 
succession  the  calf  and  thigh  if  necessary. 

The  next  movement  is  addressed  to  the  deeper  structures.  The 
rubber's  thumbs  should  be  applied  against  the  skin  and  with  a 
rotary  movement  the  skin  should  be  moved  over  the  deeper  struc- 
tures while  considerable  light  pressure  is  exerted.  It  is  accom- 
plished by  always  sliding  the  thumbs  a  little  at  the  end  of  each 
rotation. 

The  only  other  movement  which  is  necessary  is  a  deep  kneading 
of  the  muscles.  This  is  done  with  the  palm  of  the  hand  grasping 
the  muscles  and  kneading  them  gently,  using  much  the  same  motion 
that  one  does  in  kneading  dough.  This  should  be  carried  from 
the  toes  to  the  body  like  the  others.  Lastly  the  joints  should  be 
gently  and  firmly  carried  through  their  normal  arc  of  motion  sev- 
eral times.  The  whole  manipulation  should  occupy  twenty  or 
thirty  minutes,  and  the  most  suitable  time  is  at  bedtime.  By 
this  means  the  limb  has  complete  rest  after  the  massage  and  the 


JNFAN'IJIJ':  SI'INAL    l'y\ KA L\'SIS.  563 

voluntary  muscular  exercises,  about  to  be  mentioned,  sliouhl  either 
follow  or  precede  the  massage. 

In  the  place  of  the  usual  manual  massage,  mechanical  massage 
of  the  limbs  has  been  employed  by  means  of  carefully  constructed 
appliances.  This,  hpwever,  will  be  within  the  reach  of  but  few, 
and  can  hardly  be  recommended  as  offering  any  greater  benefit 
than  is  obtained  by  the  ordinary  manual  massage. 

Mechanical  passive  exercises  have  been  used  in  cases  of  infantile 
paralysis,  but  the  benefit  to  be  obtained  from  them  is  slight. 

Active  muscular  exercise  of  the  paralyzed  limb  is  a  most  desira- 
ble tonic  to  the  affected  muscles,  however  it  is  obtained,  provided 
the  muscles  be  not  overtaxed.  With  the  assistance  of  the  parent's 
hand,  a  foot  which  naturally  drops  forward  from  paralysis  of  the 
anterior  leg  muscles,  can  be  flexed,  and  with  each  repetition  of  the 
exercise  the  muscle  will  be  found  able  to  accomplish  more.  It  is 
impossible  to  lay  down  any  series  of  exercises.  In  each  case  the 
problem  must  be  met  differently.  The  aim  should  be  so  to  assist 
the  affected  muscles  that  if  they  have  any  power  left  they  may  be 
enabled  to  use  it  daily  for  their  own  advantage.  And  with  this  in. 
view,  assistance  should  be  rendered  by  supporting  and  aiding  the 
affected  limb  in  its  movements  in  the  Avay  most  likely  to  call  into 
use  these  paralyzed  muscles.  Such  exercise  forms  a  most  useful 
adjunct  to  the  rubbing  just  described.  It  should  be  repeated  each 
night  just  before  or  just  after  the  massage. 

H.  L.  Taylor,  in  an  excellent  paper  on  the  hygiene  of  reflex 
action,  says  :  "  In  the  neuro-muscular  degenerations  following  acute 
anterior  poliomyelitis,  it  is  especially  important  to  restore  to  the 
paretic  extremities,  so  far  as  possible,  the  stimuli  of  locomotion 
and  other  normal  associated  movements  without  the  inhibition  of 
insecure  footing  and  strained  tissues — and  it  is  for  the  specific  pur- 
pose of  restoring  to  the  damaged  cord  and  muscles  the  cutaneous, 
muscular,  and  articular  stimuli  of  locomotion  that  apparatus  is 
constructed. 

"  Normal  reflexes  of  locomotion  are  broken  up,  and  a  wasteful  and 
cumbersome  set  installed,  subject  to  constant  cerebral  interference 
in  the  efforts  at  balancing  and  progression,  and  additionally  dis- 
turbed by  the  strain  in  weakened  muscular  and  joint  structures 
which  is  rendered  inevitable  by  the  lack  of  balance  between  op- 
posing groups.  Mechanical  protection  with  muscular  training 
enables  the  patient  to  acquire  a  better  set  of  reflexes  and  promotes 
the  nutrition  of  the  part." 


564  ORTHOPEDIC  SURGERY. 

Mechanical  Treatment. 

The  mechanical  treatment  of  this  disease  often  presents  a  most 
dif^cult  problem.  Absolute  accuracy  in  the  fitting  of  the  appara- 
tus is  an  essential,  and  the  varying  indications  make  necessary  con- 
stant modifications  in  the  appliances  to  be  used. 

The  mechanical  treatment  of  infantile  paralysis  is  twofold  in  its 
object.  The  first  and  simplest  use  of  apparatus  is  to  support  and 
protect  the  paralyzed  limb  in  such  a  way  that  the  muscles  shall 
work  to  the  best  advantage  and  that  the  joints  may  be  supported 
and  controlled.  By  doing  this  the  occurrence  of  contraction  de- 
formities is  prevented  and  the  nutrition  of  the  limb  is  kept  in  the 
best  possible  condition  by  enabling  the  limb  to  be  used  in  a  com- 
paratively normal  way. 

The  second  function  of  mechanical  treatment  in  infantile  paraly- 
sis is  to  overcome  by  means  of  suitable  appliances  deformities 
which  have  already  occurred  and  to  prevent  their  recurrence ;  it 
may  often  be  necessary  to  attempt  both  objects  with  one  appara- 
tus. 

TJie  Indications  for  Mechanical  Treatmerit. — Whenever  a  paralyzed 
limb  is  unable  to  bear  the  weight  of  the  body  which  falls  upon  it 
in  locomotion,  some  mechanical  help  is  manifestly  advisable.  This 
is  not  only  needed  where  the  paralysis  is  complete,  but  also  when 
owing  to  incomplete  muscular  strength  more  strain  is  borne  on  the 
articular  ligaments  than  is  normal,  and  distortion  follows.  More- 
over when  the  bearing  of  the  body  weight  or  the  act  of  walking 
throw^s  the  foot  or  the  leg  into  any  abnormal  position,  the  use  of 
some  appliance  is  indicated. 

It  is  difificult  to  describe  the  various  appliances  needed  in  the 
treatment  of  infantile  paralysis,  and  much  must  be  left  to  the  in- 
genuity of  the  surgeon  in  each  case.  The  first  division  of  the  me- 
chanical treatment  of  these  cases  consists  in  furnishing  sufficient 
support  to  the  limb  in  the  following  conditions: 

1st.   Paralysis  of  the  muscles  of  the  legs  and  feet. 

2d.   Paralysis  of  the  muscles  of  the  thigh. 

3d.   Paralysis  of  the  muscles  of  the  back. 

And  a  combination  of  these  various  paralyses. 

Paralysis  of  the  Leg. — When  the  muscles  of  the  leg  are  paralyzed, 
those  which  help  to  control  the  ankle-joint  in  standing  and  walking 
are  rendered  inefficient  and  the  ligaments  become  relaxed  so  that 
in  the  standing  position  the  ankle  of  the  affected  side  cannot  sustain 
the  body  weight  as  it  should  and  the  foot  is  apt  to  roll  in  or  out,  caus- 
ing an  inversion  or  eversion  of  the  foot  amounting  to  a  degree  of 
talipes  varus  or  valgus.    Another  source  of  disability  is  in  the  drop- 


INI''ANT/LE  SJ'/NA/.    J'ARA LYSIS.  565 

ping  of  the  toes  in  wiilkin^,  vvliicli  dra^rand  render  the  [^ait  unsightly 
and  difficult.  This  results  from  jiaralysis  of  the  anterior  muscles  of 
the  leg,  which  fail  to  raise  the  anterior  part  of  the  foot  as  they  siiould 
do.  A  common  appliance  for  this  latter  deformity  is  an  ordinary 
shoe  fitted  with  lateral  steel  uprights,  which  have  a  right-angle 
stop  catch  at  the  ankle  which  kee[js  the  foot  from  being  fully  ex- 
tended, but  which  is  without  a  steel  sole  plate.  It  may  be  said  of 
this,  as  of  all  similar  apparatus  which  is  attached  simply  to  the  out- 
side of  the  sole,  that  the  leather  sole  bends  and  the  upper  of  the 
boot  stretches,  so  that  the  appliance  soon  comes  to  furnish  an  inac- 
curate and  yielding  support  to  the  ankle,  and  that  all  apparatus  of 
this  sort,  without  a  steel  sole,  is  to  be  avoided,  although  much  used 
by  the  instrument  makers.  This  is  also  true  of  similar  appliances 
furnished  with  an  anterior  rubber  band  ("  artificial  muscle  ")  run- 
ning from  the  toe  of  the  boot  to  the  top  of  the  upright.  Without 
a  steel  sole  plate  in  the  shoe  the  apparatus  will  soon  lose  its  effi- 
cacy. 

In  any  apparatus  which  is  to  sustain  the  foot  in  its  weight-bear- 
ing function,  accuracy  of  support  is  indispensable,  and  a  simple 
leather  boot,  however  stout  it  may  be,  soon  yields  and  the  foot 
slips  away  from  the  rest  of  the  apparatus,  and  the  efficiency  of  the 
brace  is  impaired ;  a  rigid  sole  is,  therefore,  essential  for  any  appa- 
ratus which  is  to  control  the  ankle  properly,  and  this  can  easily  be 
accomplished  by  having  a  thin  steel  plate  inserted  between  the 
layers  of  the  sole  of  the  boot. 

Where  no  contraction  or  deformity  exists  at  the  ankle,  but  there 
is  simply  a  tendency  of  the  front  of  the  foot  to  drop  on  account  of 
the  affection  of  the  anterior  muscles  of  the  leg,  locomotion  can  be 
made  much  more  easy  by  preventing  this. 

This  can  be  accomplished  by  the  application  of  a  walking  appli- 
ance, described  under  club-foot  as  a  varus  shoe  (Chap.  XIII. ),  which 
should  be  provided  with  a  right-angle  stop  at  the  ankle  which  will 
not  allow  the  ankle  to  be  extended  to  more  than  a  right  angle,  or  a 
simple  sole  plate  of  steel  or  tin  may  be  attached  to  uprights  which 
are  at  right  angles  to  it  and  which  extend  up  the  leg,  ending  above 
in  a  posterior  calf  band.  If  the  foot  is  bandaged  to  this,  and  the 
uprights  are  attached  to  the  leg,  the  foot  will  be  held  in  a  perma- 
nently correct  position,  and  if  desired  a  joint  at  the  ankle  can  be 
provided  which  will  flex  but  yet  will  not  allow  the  foot  to  be  ex- 
tended beyond  a  right  angle.  When  in  bearing  weight  upon  the 
leg  the  ankle  assumes  a  varus  position,  the  same  \'arus  shoe  Avill 
correct  the  tendency  to  deformity. 

If  the  foot  rolls  out  and  is  everted  into  a  valgus  condition  when 
the  body  weight  is  borne  upon  the  leg,  an  outside   shoe  is  to  be 


566 


ORTHOPEDIC  SURGERY. 


applied,  in  construction  like  the  varus  shoe,  but  which  should  have 
a  broad  leather  strap  which  should  pass  around  the  inner  malleolus 
and  support  it.  This  apparatus  is  a  difificult  one  to  render  quite 
comfortable  to  the  patient,  as  much  weight  must  necessarily  come 
upon  the  strap  which  supports  the  inner  malleolus.  As  flat-foot  is 
almost  always  present  in  these  cases,  it  is  well  to  arch  the  steel  sole 
plate  of  this  apparatus  so  that  it  serves  as  a  valgus  plate  as  well  as 
a  supporting  appliance.     The  appliance  is  shown  in  the  figure. 

It  will  in  this  way  often  remedy  the  eversion  of  the  foot.     It  is 
manifest  that  the  simpler  and  lighter  these  appliances  are  and  the 


Fig.  566. — Valgus  Shoe  for  Infantile  Paralysis. 


less  unsightly,  the  more  serviceable  they  will  prove.  For  this 
reason  they  should  be  carefully  fitted  and  the  uprights  made  to 
follow  the  outline  of  the  leg.  In  very  slight  cases,  where  there  is 
only  a  slight  eversion  of  the  foot  with  a  small  degree  of  valgus,  a 
common  valgus  plate,  such  as  would  be  applied  for  flat-foot,  will 
often  answer  every  purpose  in  correcting  the  abnormity,  and  it 
should  be  applied  as  in  simple  flat-foot. 

In  severe  cases  of  paralysis  of  the  muscles  of  the  legs  and  foot, 
the  thigh  muscles  are  also  involved.  The  same  appliance  will  often 
have  to  support  the  knee  and  thigh  as  well  as  to  correct  deformity 
at  the  ankle.  But  this  involves  merely  an  extension  of  the  appa- 
ratus up  the  leg. 


INFANT! I. !■:   Sl'JNAL   J'ylA'ALYS/S. 


567 


Paralysis  of  tJic  lltioji  Muscles.  -When  the  muscles  of  the  thigh 
are  involved  in  the  paralysis,  the  limb  becomes  unable  to  sustain 
the  weight  thrown  upon  it  and  the  knee  flexes  and  the  limb  drops 
forward  when  weight  is  borne  upon  it.  The  knee-jr;int  does  not 
bend  to  one  side  or  the  other,  as  the  lateral  ligaments  retain  much 
strength.  In  a  few  instances  the  knee  will  drop  backward  to  more 
than  a  straight  line,  but  owing  to  the  strength  f;f  the  crucial  liga- 
ments, in  infantile  paralysis  it  never  falls  so  far  back  as  to  be  unable 
to  sustain  weight.  For  the  practical  purposes  of  locomotion,  there- 
fore, it  is  only  essential  that  the  knee  be  prevented  from  dropping 
forward,  and  this  can  be  done  by  means  of  any  appliance  which  will 
press  the  knee  backward.     The  simplest  way  of  doing  this  is  by 


Fig.  567. — Supporting  Appliance  in  Paralysis  of  the  Anterior  Thigh  IMuscles. 


the  use  of  two  steel  rods  reaching  from  the  back  of  the  thigh  to 
the  bottom  of  the  shoe.  These  rods  are  placed  on  the  outer  and 
inner  side  of  the  limb  and  are  connected  at  the  top  by  a  posterior 
steel  band,  which  furnishes  a  counterpoint  of  pressure  by  which  to 
hold  the  knee.  If  a  strap  is  passed  in  front  of  the  knee,  it  is  im- 
possible for  it  to  drop  forward  when  weight  is  thrown  upon  the 
leg,  and  the  patient  can  stand  upon  the  limb.  The  appliance  sup- 
plies the  check  normally  exercised  by  the  muscles.  Below  it 
should  be  fitted  to  a  boot,  or  if  the  muscles  of  the  leg  are  also  in- 
volved, to  one  of  the  appliances  such  as  the  varus  or  valgus  shoe 
mentioned  above.  The  principle  of  such  apparatus  in  retaining 
the  knee  extended  is  shown  in  the  figure  (Fig.  567"). 

Instead  of  being  applied  by  means  of  a  steel  sole  plate,  the  ap- 


568  ORTHOPEDIC  SURGERY. 

paratus  may  be  fastened  to  the  sole  of  the  boot  (Fig.  568).  In  addi 
tion  to  the  bands  shown  in  the  figure,  leather  lacings  to  retain  the 
thigh  and  calf  will  probably  be  needed  to  give  the  apparatus  greater 
stability,  as  the  lacings,  by  covering  a  large  area  of  skin,  substitute 
surface  pressure  for  the  point  pressure  given  by  narrow  straps. 
This  is  a  matter  to  be  considered  in  all  supporting  apparatus. 

If  the  knee  tends  to  drop  backward  and  become  hyper-extended, 
it  can  be  remedied  by  a  similar  appliance  with  a  strap  passing  be- 
hind the  knee  with  an  upper  band  encircling  the  thigh.     In  prac- 


FiG.  563.  Fig.  569.  Fig.  570.  Fig.  571. 

Fig.  570.— Splint  with  Single  Upright  for  Infantile  Paralysis  of  Right  Leg  with  varus  Deformity  of  Ankle. 
Fig.  571. — Same  Applied,  Showing  Construction  of  Apparatus. 

tice  this  apparatus  can  often  consist  of  a  single  outside  upright 
hinged  at  the  knee,  such  as  is  shown  in  the  figure,  where  it  passes 
to  the  inside  of  the  leg  just  below  the  knee  to  become  attached  to 
a  varus  shoe.  This  answers  as  well  as  a  double  upright  in  many 
cases.  The  apparatus  can  be  hinged  at  the  knee  for  convenience 
in  sitting  down  and  should  be  furnished  with  leather  lacings  for 
the  thigh  and  calf. 

The  figures  show  the  apparatus  as  applied  and  an  outline  draw- 
ing of  the  splint  without  lacings  or  straps  (Figs.  570  and  571). 

Other  cases,  where  the  paralysis  is  more  severe,  require  the  two 
uprights,   as    they  furnish   a    more    definite    support.     The   figure 


INFANTILE  SPINAL  PARALYSIS, 


569 


(Fig.  572)  shows  such  an  appHancc  applied  and  unapplied,  without, 
however,  the  lacings  for  the  thigh  and  calf  and  foot.  The  foot  is 
easily  retained  to  the  steel  sole  plate  by  straps  or  a  piece  of  leather 
lacing  over  the  instep.  The  fenestrated  knee-cap  is  the  most  com. 
fortable  method  of  holding  the  knee  extended. 

Although  in  walking  it  is  generally  necessary  to  have  the  knee 


t3 


O 


Fig.  572.—  Supporting  Appliance  for  Infantile  Paralysis  of  Leg  and  Thigh  with  Knee  Cap. 


kept  extended  by  the  splint,  yet  in  sitting  down  it  is  a  great  com- 
fort to  the  patient  to  be  able  to  flex  the  knee,  and  for  this  reason 
nearly  all  splints  are  hinged  at  the  knee. 

A  great  variety  of  hinges  can  be  applied  at  the  knee  with  differ- 
ent catches  enabling  the  patient  to  bend  the  limb  by  loosening  the 
catch  or  locking  it  when  it  is  desired  that  the  limb  should  be  stiff. 
The   simplest   and   most   economical  of  these   is  the  simple   drop 


570 


ORTHOPEDIC  SURGERY. 


catch  shown  in  the  figure.  When  the  hmb  is  straightened,  the  ring 
falls  down  and  locks  the  splint  in  the  extended,  position,  but  it  can 
be  pulled  up  at  any  time,  allowing  the  knee  to  bend. 

In  another  and  more  expensive  form  the  splint  is  self-locking, 
and  the  bending  is  made  possible  by  pressing  a  handle  at  the  out- 
side of  the  knee. 

Where  the  adductor  muscles  are  affected,  little  or  nothing  can 
be  done  to  supplement  them  by  mechanical  means  without  em- 
ploying heavy  apparatus,  inasmuch  as  their  loss  of  power  only 
occurs  in  extensive  paralysis.  This  can  be  done  by  encircling  the 
pelvis  by  a  stout  leather  band  which  is  connected  with  the  leg  ap- 


f.^v-^^v^i-'-V-^i 


O 


Fig  573.— Drop  Catch. 


Fig.  574.  I'lG.  575- 

Figs.  574,  575. — Self-Locking  Spring  Catch. 


pliance  by  joints  at  the  hip.  The  appliance  shown  in  Fig.  576  is 
a  useful  form  of  this  sort  of  apparatus,  and  even  in  very  extensive 
paralysis  of  both  legs  it  may  furnish  much  support.  Little  can  be 
done  to  remedy  paralysis  of  the  glutei  muscles,  but  when  paraly- 
sis of  the  legs  appears  to  be  complete,  a  certain  amount  of  relief 
may  be  given  by  attaching  the  leg  uprights  to  a  leather  or  silicate 
jacket.  The  common  Thomas  knee  splint  may  be  joined  to  a 
leather  jacket  by  lateral  uprights  jointed  at  the  trochanter,  and 
the  two  may  be  jointed  at  the  knee,  and  thus  imperfect  locomotion 
may  be  H)ade  possible  to  a  child  who  would  otherwise  be  bedridden. 
The  muscles  of  the  back  are  rarely  if  ever  paralyzed,  except  in 
connection  with  palsy  of  some  of  the  muscles  of  the  leg.     Com- 


INFANTILE  SPINAL    /'ANALYSIS. 


571 


pletc  paralysis  of  the  muscles  of  the  trunk  indicates  an  extent  of 
disease  which  is  beyond  mechanical  aid.  Where  the  muscles  of 
the  back  are  but  partially  affected,  help  may  be  afforded  by  the 
use  of  corsets  or  other  supporting  appliances,  such  as  are  employed 
in  the  deformities  of  the  spine.  These  can  be  connected  with  the 
leg  appliances  and  will  afford  assistance  in  standing.  Cases  of  this 
sort  may  be  so  severe  as  to  require  the  use  of  crutches  for  rapid 
locomotion,  but  much  assistance  may  be  afforded  by  appliances  in 
many  cases. 

The  abdominal  muscles  are  sometimes,  though  rarely,  affected, 


^^H 

^^^^H 

JiiilliiiBKfr^?  ^r™W 

wWmKHmmmi\^      1 " '  ^  ■mi  if 

!■ 

Ih 

H 

EiG.  576. — Burrell's  Splint  for  Complete 
Infantile  Paralysis  of  Both  Legs. 


Fig    577. — Jacket  and  fointcd  Uprights  for  Use  m  Casrs  of 
Complete  Parahbis  of  Both  Legs 


giving  a  protuberant  abdomen,  and  a  position  of  much  lordosis  in 
standing.  Waist  bands  or  corsets  will  serve  to  correct  the  appear- 
ance of  the  trunk  to  a  certain  extent. 

The  mechanical  treatment  of  infantile  paralysis  of  the  arm  is  not 
a  question  which  arises  often  enough  to  make  it  worth  while  to 
enter  upon  any  discussion  of  it,  save  to  mention  that  the  principles 
of  treatment  are  the  same  as  those  already  considered. 

The  use  of  elastic  bands  to  supply  the  place  of  the  disabled 
muscles  is  not  infrequent   in  the  treatment  of  infantile  paralysis, 


572 


ORTHOPEDIC  SURGERY. 


and  is  thought  in  some  instances  to  be  sufficient  to  compensate  for 
the  action  of  the  paralyzed  muscles.  It  will,  however,  be  found 
that  an  elastic  support,  inasmuch  as  it  is  not  of  certain  tension,  is 
necessarily  a  varying  support  and  adds  to  the  complicated  nature 
of  the  appliance  rather  than  to  its  efficiency,  nor  is  it  possible  to 
gauge  accurately  the  force  or  pressure  exerted  at  any  time.  It  is 
generally,  therefore,  a  much  less  efficient  form  of  apparatus  than  the 
rigid  forms  here  advocated. 

Mechanical  Treatment  as  Applied  to  the  Correction  of  the  Deformity. 
■ — Whether  the  deformity  shall  be  corrected  by  purely  mechanical 
means  or  by  operative  interference,  depends  not  only  upon  the 
nature  of  the  distortion,  but  also  the  time  at  the  disposal  of  the 
patient  and  surgeon.  Almost  all  distortions  of  this  sort  can  be 
cured  in  children  without  any  operative  interference,  as  all  that  is 
required  is  the  stretching  of  the  fasciae  and  the  contracted  tendons. 
These  distortions  are  either  flexions  at  the  hip  or  knee  or  some 
distortion  of  the  ankle.  As  a  rule  these  distortions  yield  readily 
upon  the  application  of  efficient  force. 

Deformity  at  the  hip,  which  is  generally  flexion,  with  perhaps  abduc- 
tion is  the  hardest  of  all  the  deformities  of  infantile  paralysis  to  cor- 
rect by  mechanical  means  on  account  of  the  difficulty  of  securing  a 
fixed  hold  upon  the  pelvis,  by  which  a  point  of  resistance  can  be  se- 
cured in  overcoming  the  flexion  of  the  thigh.  A  simple  apparatus 
which  is  often  of  use  is  furnished  by  two  calliper  Thomas  knee  splints, 
or  one,  as  the  case  may  be,  attached  to  a  leather  jacket  by  side  irons 
hinged  opposite  to  the  hips.  To  the  posterior  and  upper  parts  of 
the  splints  are  attached  straps  which  buckle  to  the  back  of  the 
jacket,  and  while  by  the  jacket  as  firm  a  hold  as  possible  is  taken 
on  the  pelvis;  when  the  straps  are  buckled  the  calliper  splints 
pull  the  legs  backward  and  tend  to  overcome  the  flexion  at  the 
hips.     During  this  time  the  child  should  go  about  on  crutches. 

But  the  contraction  is  sometimes  resistant  and  it  is  necessary 
to  confine  the  patient  to  the  bed  and  employ  traction  of  a  consid- 
erable amount  and  such  measures  as  have  already  been  described 
in  correction  of  the  flexion  deformity  of  hip  disease. 

Attempts  to  use  the  weight  of  the  leg  to  correct  this  flexion  in 
severe  cases  are  of  little  use.  It  might  be  imagined  that  if  the 
knee  were  straightened  by  a  ham  splint,  and  the  patient  allowed  to 
go  about  on  crutches  with  the  leg  projecting  in  front  of  him,  the 
weight  of  it  by  dragging  upon  the  shortened  tissues  would  stretch 
them  and  the  flexion  would  be  diminished.  But  the  leg  hangs 
almost  perpendicularly  down  in  these  cases,  owing  to  a  compen- 
satory lordosis  in  the  lumbar  spine,  which  takes  place  at  once. 
This  is  due  to  the  rotation  of  the  pelvis  upon  its  transverse  axis, 


INFANTn.l<:  SPINAL    PARALYSIS.  573- 

which  occurs  naturally  cnout^li  under  the  influence  of  the  weight 
of  "the  Ic^  and  which  occasions  no  inconvenience  to  the  patient.  A 
similar  proceedinj^  occurs  when  a  weight  is  applied  to  the  patient's 
leg  lying  in  bed  so  that  it  becomes  inefficient  also.  In  short,  flex- 
ion at  the  hip  is  a  very  stubborn  deformity,  which  will,  however, 
generally  yield  to  mechanical  measures  if  faithfully  persisted  in. 
In  severe  cases,  however,  when  mechanical  treatment  fails  opera- 
tive measures  are  to  be  considered. 

Flexion  of  t lie  knee  is  due  to  a  contraction  cjf  the  hamstring  mus- 
cles. The  deformity,  except  in  very  severe  cases,  can  be  corrected 
by  bandaging  the  leg  to  a  splint  which  takes  pressure  above  on  the 
under  side  of  the  thigh  and  below  is  fastened  to  the  heel.  The  ap- 
pliance is  similar  to  that  described  above  as  a  support  to  the  knee. 
In  resistant  cases  some  pain  is  experienced  in  this  procedure,  but 
the  pain  is  not  great  and  in  the  lighter  cases  the  deformity  can  be 
usually  overcome.  Patients  with  the  severest  deformity  should 
be  confined  to  bed  during  the  application  of  this  method  of  treat- 
ment, but  in  the  milder  cases  they  may  be  allowed  to  go  about. 

The  simplest  of  all  forms  of  correction  in  contraction  of  the 
knee  is  the  Thomas  knee  splint  or  a  modification  of  it,  but  jointed 
splints  will  be  found  convenient  in  some  instances  of  the  severest 
type.  If  the  Thomas  knee  splint  is  applied,  a  bandage  should  be 
applied  in  front  of  the  thigh  and  behind  the  calf;  by  tightening 
these,  a  decided  extension  force  is  exerted  upon  the  knee. 

An  admirable  brace  for  correction  of  the  knee  is  furnished  by 
one  similar  to  the  simple  supporting  brace  with  two  uprights 
already  described,  except  that  it  should  be  jointed  at  the  knee  and 
furnished  on  one  side  with  a  worm  screw  and  ratchet,  so  that  by 
the  use  of  a  key  the  splint  could  be  set  with  any  desired  angle  at 
the  knee.  A  leather  knee  cap  is  sometimes  necessary  to  obtain 
counter  pressure  against  the  knee  in  front,  but  in  other  cases  the 
thigh  and  calf  lacings  are  sufficient  to  obtain  any  desired  leverage. 
These  leather  lacings  should  fit  with  especial  accuracy  in  this  form 
of  appliance. 

To  be  applied  the  splint  should  be  flexed  to  fit  the  contracted 
knee  and  put  on  and  laced  tightly.  Then  with  the  key  it  should 
be  extended  nearly  to  the  point  of  endurance  and  worn  as  straight 
as  it  can  be  borne  for  an  indefinite  time.  At  first  these  joints 
prove  very  sensitive  and  painful,  but  they  soon  become  used  to  the 
tension  and  then  rapid  progress  can  be  made.  The  extension  of  a 
badly  contracted  knee  may  in  the  case  of  an  adult  be  a  matter  of 
many  months,  but  in  children,  at  any  rate,  it  can  practically  always 
be  accomplished,  provided  the  requisite  amount  of  attention  can 
be  given  to  it  by  the  parents.  The  deformity  shows  a  strong  ten- 
dency to  recur  when  the  apparatus  is  removed. 


574 


ORTHOPEDIC  SURGERY. 


It  would  hardly  be  possible  to  reduce  the  knee  flexion  by  band- 
aging the  leg  to  a  ham  splint  and  making  traction  upon  the  knee; 
the  resistance  is  too  obstinate  except  in  very  slight  cases.  Again 
the  Billroth  splint  (described  and  figured  under  tumor  albus)  may 
be  found  useful.  Correction  by  the  repeated  application  of  plaster 
bandages  to  the  knee  extended  as  much  as  possible,  will  often  be 
found  satisfactory,  and  painless  to  the  patient.  The  method,  how- 
ever, is  a  slow  one  in  resistant  deformities. 

The  treatment  of  the  deformities  of  the  ankle-joint  caused  by 
infantile  paralysis  differs  very  little  from  that  described  in  the 
chapters  describing  deformities  of  the  foot.  These  deformities., 
however,  are  rarely  so  resistant,  and  yield  more  readily  to  mechani- 
cal treatment.  Talipes  equino-varus  and  varus  are  ordinarily  to 
be  corrected  by  the  varus  shoe,  so  often  described.  In  severe 
cases  which  seem  resistant,  and  in  adults,  tenotomy  will  save  time 
and  annoyance. 

Talipes  valgus  is  rarely  the  result  of  contraction,  but  exists  more 
as  a  purely  static  deformity,  the  treatment  of  which  has  been 
already  considered. 

Talipes  calcaneus  and  pes  cavum  are  not  susceptible  of  much 
improvement  by  mechanical  treatment..  Apparatus  which  depends 
for  its  efificiency  upon  a  strap  encircling  the  instep  and  pressing 
upon  the  head  of  the  astragalus  fails  to  accomplish  very  much.  At 
times  it  is  of  use  to  apply  an  outside  or  inside  Taylor  shoe,  as  the 
case  may  be,  with  a  right-angle  stop  catch  joint  at  the  ankle,  which 
prevents  flexion  of  the  foot  further  than  that  angle.  Further  de- 
tails of  the  treatment  are  considered  in  Chapter  XXIV. 

Operative  Treatment. 

The  operative  treatment  of  the  deformities  of  infantile  paralysis 
is  to  be  considered  when  the  deformity  is  very  severe,  when  a 
speedy  result  is  desired  for  any  reason,  when  the  patient  cannot 
afford  apparatus,  or  the  parents  are  not  intelligent  or  faithful 
enough  to  follow  out  mechanical  treatment. 

The  measures  to  be  considered  are: 

Tenotomy. 

Forcible  straightening. 

Osteotomy. 

Excision. 

Tenotomy. — The  technique  of  tenotomy  done  for  these  contrac- 
tions is  the  same  as  that  of  tenotomy  in  general. 

Immediate  correction  is  advisable  after  tenotomy  in  these  as  in 
other  deformities,  but  over-correction  is  not  necessary.     A  reten- 


INFANTJU'l  Sl'IXAL    J'ARALYSIS. 


575 


tive  walking  appliance  is  needed  to  prevent  relajjsc,  although  re- 
lapse is  not  nearly  so  lik-ely  to  occur  as  after  tlie  correction  of  cor- 
responding congenital  deformities. 

Tenotomy  of  the  hip  for  contraction  in  the  flexed  position  may 
in  the  severest  cases  be  far  from  a  trifling  operation,  and  should  be 
undertaken  with  due  reserve.  The  contraction  is  due  not  only  to 
the  contraction  of  the  superficial  tissues,  but  of  the  deep  muscles 
also  and  often  of  the  joint  capsule,  and  for  that  reason,  when  the 
operation  is  undertaken  in  a  severe  case,  it  is  better  not  to  attempt 
a  subcutaneous  tenotomy,  but  at  once  to  make  a  longitudinal  open 
incision  of  considerable  length  over  the  contracted  tissues,  and 
preparation  should  be  made  to  go  as  deep  as  the  psoas  tendon  if 
necessary.  Although  the  contraction  often  seems  to  be  superficial, 
a  division  of  the  superficial  bands  generally  gives  but  little  relief, 
and  all  constricting  bands  must  be  cut,  except  of  course  the  cap- 
sule of  the  hip-joint,  which  often  offers  much  resistance.  A  con- 
servative method  to  pursue  is  to  cut  the  superficial  contracted  tis- 
sues and  to  divide  the  psoas  tendon  nearly  across,  cutting  also 
those  deep  structures  which  are  plainly  in  view,  in  order  to  be  able 
to  check  hemorrhage  if  it  begins;  then  to  close  the  wound  and  to 
apply  a  bed  extension  to  the  leg,  which  will  have  the  effect  of 
stretching  the  remaining  structures  quite  readily  until  a  corrected 
position  is  obtained.  Tenotomy  of  the  ham-string  muscles  at  the 
knee  and  of  the  leg  muscles  in  talipes  equinus  and  varus  requires 
no  comment. 

Talipes  calcaneus  is  to  be  improved  by  the  operation  advocated 
by  Walsham  and  Willett,'  which  is  not  attended  by  much  risk, 
and  gives  some  hope  of  improvement  in  a  deformity  otherwise 
practically  irremediable.  It  consists  in  shortening  the  stretched 
tendo  Achillis  from  one-half  to  two-thirds  of  an  inch.  The  incision 
should  be  made  through  the  tendon  obliquely  from  above  down- 
ward and  from  before  backward,  and  then  the  cut  ends  should  be 
slid  past  each  other  until  the  desired  shortening  is  effected  ;  in  that 
position  they  should  be  stitched  together  by  catgut  or  kangaroo 
tendon  very  firmly,  and  several  sutures  should  be  taken  through  the 
skin,  also  uniting  it  to  the  tendon,  to  produce  as  firm  and  dense,  a 
cicatrix  as  possible.  It  is  better  not  to  remove  any  piece  of  the 
tendon,  but  to  shorten  it  in  the  manner  described.  The  results  of 
this  procedure  are  generally  very  satisfactory;  certain  cases  regain 
the  power  of  flexion  and  extension  of  the  foot,  and  the  muscles  of 
the  calf  tend  to  increase  in  size  and  in  part  to  regain  their  lost 
functions.     Much  care  should  be  taken  not  to  allow  the  patient  to 

^  Brit.  j\Ied.  Journal,  Jwi'e  14th,  1SS4:    May  31st,  1SS4. 


5;6  ORTHOPEDIC  SURGERY. 

walk  on  the  foot  until  time  enough  has  been  given  to  the  tendon 
to  become  firmly  united. 

Mr.  Keetly "  resected  the  quadriceps  extensor  tendon  in  a  case 
where  it  was  paralyzed  and  stretched  and  extension  of  the  leg  was 
not  possible.  A  longitudinal  incision  was  made  and  one  inch  of 
the  muscle  removed  about  two  inches  above  the  patella,  and  the 
cut  ends  sutured  with  catgut.  The  leg  was  put  on  a  splint  and 
elevated  60°  to  relax  the  muscle  as  much  as  possible.  A  procedure 
was  adopted  in  a  case  of  talipes  calcaneus  by  Nicoladoni  which 
was  followed  by  much  benefit.-^  The  calf  muscles  were  paralyzed, 
although  the  peronei  were  intact,  and  the  foot  could  not  be  ex- 
tended. The  tendo  Achillis  was  divided  and  the  peroneal  tendons 
were  sewed  to  that,  so  that  by  their  contraction  they  might  elevate 
the  heel.  There  was  a  decided  gain  in  walking.  The  procedure 
has  been  repeated  by  other  surgeons  with  success. 

Forcible  straigJitening  is  applicable  to  the  knee,  hip,  and  ankle, 
and  is  of  course  to  be  done  under  complete  anaesthesia.  Gibney^ 
advocates  the  method  and  it  will  be  found  an  available  one. 

Excision. — The  immediate  object  of  operative  procedures  in  the 
case  of  flail  joints  is  to  secure  a  stiff  joint  instead  of  one  excessively 
movable,  by  opening  and  scraping  out  the  synovial  cavity  or 
by  removing  the  articular  cartilages  or  even  making  a  thin  slice  of 
the  bones  on  each  side  of  the  joint  and  retaining  the  refreshed  sur- 
faces in  apposition,  so  that  ankylosis  may  be  favored,  and  the  limb 
may  thus  become  of  more  use  in  locomotion. 

Zinsmeister  writes  advising  the  procedure  of  making  an  artificial 
ankylosis  in  joints  which  are  useless  from  paralysis.  Albert  was 
the  first  to  suggest  and  perform  an  operation  in  a  case  of  infantile 
paralysis  in  which  the  knee  was  almost  a  flail  joint  and  was  useless. 
He  resected  the  knee-joint  in  order  to  obtain  ankylosis  and  thus 
secured  a  useful  limb  independent  of  apparatus;  and  similar  cases 
are  already  reported.  In  Albert's  cases  the  ages  were  twenty- 
two,  thirteen,  and  ten  months.  Ankylosis  was  established  in  a  few 
months,  and  tlie  result  is  said  to  have  been  satisfactory,  although 
two  of  the  three  needed  apparatus  to  retain  the  foot,  the  muscles 
of  the  leg  being  also  paralyzed.* 

Winiwarter  has  repeated  this  operation,  and  Wolff  has  done  the 
same  operation  on  the  shoulder.  Lesser  and  Rydigier  have  done 
a  similar  operation  in  cases  of  paralytic  talipes,  chiefly  in  cases  of 
equino-varus.     The  result   in   all  these  cases   has   been   excellent. 

'  Brit.  Med.  Journal,  May  31st,  1884,  p,  1,058. 
=  Cent.  f.  Chir.,  Nov.  5th,  l88r. 
3  N.  Y.  Medical  Journal,  April  3d,  1886. 
-tCentralbl.  f.  Cliirurg;.,  Oct.  21st,  1882. 


INF  AN  11 L  I'l  S/'/NA  L   /'.I  U.  1 1.  )  •.S7.S'.  5  "jj 

One  patient '  of  Lesser,  seen  seven  years  after  oj>eration,  was  able 
to  walk  about  freely  without  apparatus  or  cane,  and  could  stand 
with  slight  help  some  little  time  upon  the  lame  foot.  The  ankle  of 
course  was  ankylosed  and  there  was  an  increased  amount  of 
motion  at  the  Chopart  articulation.  The  patient  walked  well  and 
upon  the  flat  of  the  foot.  Albert  reports  a  case  in  which  the 
ankle-joint  of  a  child  eleven  years  old  was  opened  and  the  carti- 
laginous surfaces  of  the  tibia  and  astragalus  were  removed,  with  the 
result  of  a  useful  limb. 

From  the  reports  of  cases  and  the  results  attending  this  opera- 
tion, it  may  be  stated  that  in  very  severe  deformities  and  in 
patients  of  the  poorer  class,  the  question  of  resection  of  the  joint 
surfaces  of  the  knee  and  ankle  is  to  be  seriously  considered  =^  as  a 
means  of  treatment  in  preference  to  the  application  of  apparatus. 

In  other  cases  resection  of  joints  ^  is  to  be  considered  on  account 
of  the  extreme  bony  deformity  which  they  present. 

At  the  knee-joint,  knock-knee  may  be  so  severe  that  the  leg 
forms  a  great  angle  with  the  thigh.  In  these  cases  mechanical 
treatment  is  not  likely  to  remedy  the  deformity.  One  must  resort 
to  either  resection  of  the  joint,  or,  as  has  been  suggested ''  by  Mol- 
liere,5  osteotomy.  Molliere  believes  that  deformities  formerly  de- 
manding resection  may  now  be  corrected  by  osteoclasis. 

In  genu  varum  and  valgum,  osteoclasis  is  greatly  to  be  preferred 
to  resection.  He  reports  one  hundred  cases  without  any  accident. 
In  all  cases  excepting  those  involving  the  elbow-joint  preference  is 
given  to  osteoclasis  for  thorough  and  safe  reduction  of  the  deform- 
ity. Oilier,  and  with  him  most  American  surgeons,  prefer  the  re- 
moval of  wedge-shaped  pieces  of  bone  or  a  simple  excision  in  opera- 
tions about  the  joints ;  for  the  latter  operation  possesses  the  ad- 
vantage in  this  case  of  leaving  a  stiff  joi-nt. 

In  very  severe  contraction  at  the  hip-joint  subtrochanteric  osteot- 
omy should  be  considered  as  an  alternative  to  a  deep  tenotom.y,  as 
it  would  hardly  prove  a  more  serious  operation.  It  should  be 
done  precisely  in  the  way  described  for  the  correction  of  ankylosis 
of  the  hip  after  hip-joint  disease.  The  technique  of  operating  in 
the  cases  of  flail  joints  would  be  very  similar  to  the  simple  exci- 
sions already  described. 

^  Centralbl.  f.  Chirurg.,  1887,  No.  46. 

=  Ap.  M.  Vance:    Bost.  Med.  and  Surg.  Journal,  May  6th,  18S6,  p.  416. 
3  Franks  and  Stocker:  Trans,  of  Acad,  of  Med.  of  Iceland,  1SS5;  Lessor:  Cent.  f.  Chin. 
1879,  No.  31,  p.  497,  and  No.  46,  18S7,  p.  797. 

''  Kolliker:    Deutsch.  Z.  f.  Chir.,  xxiv.,  591;   Revue  de  Chir.,  1SS6,  vi.,  S90. 
5  Centralb.  f.  Chirurg.,  No.  24,  1888. 

37 


CHAPTER  XVII. 

CEREBRAL    PARALYSIS    OF    CHILDREN. 

Symptoms. — Hemiplegia. — Spastic  Paralycis. — Incoordination  or  Idiocy'. — Eti- 
ology of  Cerebral  Paralysis. — Pathology  of  Cerebral  Paralysis. — Diag- 
nosis.— Diffential  Diagnosis. — Prognosis. — Treatment. 

The  term  cerebral  paralysis  is  one  whose  limits  have  not  yet 
been  very  clearly  defined  by  any  universal  usage,  and  many  other 
terms  have  been  used  as  synonymous  with  it,  but  the  term  cerebral 
paralysis  has  here  been  adopted  as  being  the  one  perhaps  the  least 
open  to  criticism.  In  the  cases  included  in  this  chapter  it  cannot 
be  always  proven  that  the  affection  is  cerebral.  Nor,  on  the  other 
hand,  is  the  affection  always  the  result  of  a  definite  muscular  paral- 
ysis, but  sometimes  there  is  present  a  rigid  contraction  of  the 
muscles  or  a  lack  of  cerebral  control.  Nevertheless  all  these  cases 
are  coming  to  be  included  under  the  general  head  of  cerebral  par- 
alysis. 

The  condition  was  first  described  by  Little  and  afterward  by 
Adams,  but  it  is  to  recent  neurologists,  Erb,  Striimpell,  Ross,  and 
others,  that  we  owe  any  understanding  of  the  nature  of  the  affec- 
tion, which  was  formerly  classed  along  with  infantile  paralysis.  It 
must  be  .remembered  that  the  affection  is  one  which  has  been  so 
recently  recognized  that  the  terminology  and  pathology  of  the 
affection  are  ill-defined. 

Motor  disturbances  in  children  which  are  due  to  cerebral  lesions 
are  manifested  clinically  as  a  rule  in  one  of  three  ways : 

(i)  As  a  loss  of  power  on  one  side  of  the  body  similar  to  the 
hemiplegia  of  adults. 

(2)  As  a  rigid  contraction  of  the  muscles  of  both  legs. 

(3)  As  a  lack  of  control  of  the  muscles  shown  in  many  different 
ways,  offering  generally,  a  group  of  symptoms  which  is  fairly  well 
represented  by  the  term  incoordination. 

The  symptoms  of  cerebral  paralysis  will,  therefore,  be  considered 
under  three  heads, 
(i)  Hemiplegia. 

(2)  Spastic  paralysis. 

(3)  Incoordination  or  idiocy. 


LKA'JC/IA'AL  J'ARA LYSIS   ()/■'  (////JJA'JCN. 


579 


Syiiiptouis  of  Hemiplegia. — The  fjnsct  of  liciniplcj^ia  may  resem- 
ble very  closely  that  of  infantile  si)inal  jjaralysis;  it  often  bej^ins 
with  an  illness  of  some  sort,  frequently  [jaralysis  develops  in  the 
course  of  an  infectious  disease,  sometimes  after  an  attack  (A  what 
seems  to  be  indigestion  or  a  sli|^ht  feverish  attack,  sometimes  after 
a  fall  or  blow  on  the  head.  Commonly  the  onset  is  marked  by 
convulsions,  as  in  52  out  of  9  of  Osier's  cases,  43  out  of  88  in  Wal- 
lenburg's,  30  out  of  80  in  Gaudard's,  12  out  of  26  in  the  Children's 
Hospital  scries,  and  "  in  more  than  half  "  of  Gowcrs'  80  cases. 
Sometimes,  however,  though  very  rarely,  the  disease  develops  sud- 
denly, in  perfectly  healthy  children  without  any  febrile  or  other 
disturbance  or  it  may  develop  insidiously  without  disturbance 
enough  to  attract  attention — even  delirium  or  screaming  spells 
may  accompany  the  onset.  The  liability  to  the  paralysis  at  differ- 
ent ages  is  worth  noticing.  In  a  certain  number  of  cases  it  is  evi- 
dently congenital,  that  is,  it  is  noted  immediately  after  birth,  and 
then  from  the  second  year  for  the  first  six  or  seven  years  of  life  the 
liability  very  gradually  diminishes;  the  number  of  cases,  however, 
rising  slightly  at  the  time  of  the  second  dentition  ;  '  in  this  respect 
it  offers  a  sharp  contrast  to  infantile  spinal  paralysis. 

When  the  paralysis  is  noticed,  it  is  found  to  be  most  often  hemi- 
plegic  in  distribution.  The  face  is  paralyzed  in  about  one-half  of 
the  cases,  and  the  arm  is  always  affected  more  severely  than  the 
leg  and  recovers  more  slowly.  The  facial  paralysis  ordinaril}'  is 
not  complete  and  does  not  affect  the  muscles  that  close  the  eyes. 
It  disappears  first  of  all  the  paralyses  and  generally  recovery  is 
complete.  Strabismus  is  very  common.  The  paralyzed  side  is 
powerless,  but  sensation  is  generally  unimpaired ;  coldness  and 
vascular  sluggishness  are  present  in  some  of  the  severer  cases. 
The  reflexes  of  the  affected  side  are  much  increased  from  the  first, 
a  sign  which  is  of  the  greatest  assistance  in  diagnosis.  As  in  the 
hemiplegia  of  adults,  rigidity  of  the  affected  muscles  comes  on  in  a 
large  proportion  of  cases  at  a  varying  time  after  the  onset  of  the 
paralysis.  At  times,  however,  the  paralyzed  arm  and  leg  remain 
flaccid  throughout.  The  rigidity,  when  present,  is  increased  by 
any  attempt  to  use  the  limb,  it  is  excited  by  passive  manipulation 
and  it  disappears  during  sleep,  and  usually  under  an  anjesthetic. 
Post-hemiplegic  movements  follow  in  a  certain  proportion  of  cases.^ 

Aphasia  accompanies  probably  a  large  proportion  of  cases  of 
cerebral  paralysis,  but  it  is  often   transitory.3     Wallenburg  found 

^  Wallenburg:    Loc.  cit. 

^  Richardson:  Bost.  Med.  and  Surg  Journal,  May  20th,  iSSo;  Hammond:  "  Uis.  of 
Nerv.  System,"  New  York,  i8S6,  p.  281;  Sharkey:  "Spasm  in  Chronic  Nerve  Dis.," 
London,  18S6,  p.  37;    Knapp. 

3  Bernhardt:    Virch.  Archiv,  Bd.  102. 


58o 


OR  THOPEDIC  S  UR  GER  Y. 


that  it  persisted  in  62  out  of  160  hemiplegias,  being  present  in  47 
per  cent  of  right  hemiplegias,  but  in  only  26  per  cent  of  left.  In 
general,  about  one-third  of  all  cases  seem  to  be  aphasic,  while  some 
imperfection  of  speech'  or  an  obscure  pronunciation  exists  in  a 
larger  number. 

Mental  enfeeblement,  varying  from  complete  idiocy  to  simple 
backwardness,  develops  in  a  large  proportion  of  all  cases.  In  the 
26  cases   in   the   Children's   Hospital   series  only  6  had  what  was 

classed  as  average  inteHigence,  and  one 
of  these  was  aphasic  and  one  stuttered 
very  badly.  Of  the  rest,  7  were  idiotic, 
8  feeble  minded,  and  4  very  backward. 
Gaudard  found  the  proportion  smaller, 
having  only  15  feeble-minded  and  19 
idiotic  children  in  80  cases,  and  Wallen- 
burg  in  his  160  cases  found  65  with  serious 
m.ental  defects,     Merklin  calls  attention  to 


Fig.  578. — Right  Sided  Hemiplegia  of 
Several  Years'  Standing.    (Knapp.) 


Fig.  579. — Atrophy  of  the  Hand  in  a  Case  of  Hemiplegia 
of  Several  Years'  Duration. 


the  fact  that  such  children  as  escape  mental  deterioration  in  child- 
hood, often  develop  psychoses  later  in  life.^ 

Epileptic  attacks  appear  in  the  paralyzed  limbs  and  thence  be- 
come generalized,  in  one-quarter  to  one-half  of  all  cases  reported. 
Ordinarily  they  come  on  in  two  or  three  years  after  the  paralysis, 
but  they  may  be  delayed,  and  ten  or  even  thirty  years  may  elapse 
sometimes;-  on  the  other  hand,  they  may  begin  within  a  few 
months  of  the  onset. 

'  Merklin:    St.  Petersburger  INIed.  Wochenschrift,  1887. 
^  Gowers:    "Epilepsy,"  London,  1880. 


CJCh'/C/l/xAI.   J'AKAD'SIS   ()/<'  CIUf.DKEN. 


581 


The  mind,  however,  may  remain  perfectly  clear  in  spite  of  a 
severe  hemiplei;ia,  and  no  sign  of  mental  deterioration  may  be 
present  in  the  early  or  the  late  history  of  the  disease. 

Unilateral  sweating  is  sometimes  seen  in  these  cases.  To  the 
later  history  of  the  affection  belong  the  atrophy  and  contractions 
of  the  limbs.  The  afTected  side  rarely  recovers  entirely  and  often 
the  growth  of  the  bones  is  retarded.  The  muscular  atrophy,  as  a 
rule,  is  not  so  great  as  in  infantile  spinal  paralysis,  but  in  certain 
cases  the  muscles  waste  until  almost  nothing  is  left  but  skin  and 
bone.  In  severe  cases  there  is  marked  arrest  of  growth  in  the 
bones.  In  the  Children's 
Hospital  series  one  case 
showed  a  shortening  of  two 
inches  in  the  arm  after  the 
paralysis  had  lasted  seven- 
teen years,  and  three  otiier 
cases  of  four,  seven,  and 
eight  years'  standing 
showed  a  shortening  of  one 
inch.  This  cannot  be  the 
atrophy  of  disuse,  as  Seelig- 
miiller  and  Henoch  have 
asserted,'  but  points  to 
some  trophic.lesion. 

The  permanent  contrac- 
tions that  come  on  are  most 
noticeable  in  the  arm,  and 
as  a  rule  are  of  one  type  in 
the  arm  and  leg.  In  the 
former  the  arm  is  held  close 
to  the  side,  the  elbow  is 
flexed  strongly  and  firmly, 
the  hand  is  flexed  and  the  fingers  drawn  into  the  palm,  usually 
embracing  the  thumb.  These  contractions  are  very  firm  and 
resisting.  The  leg  in  bad  cases  is  adducted  and  flexed  at  the  hip, 
the  hamstring  muscles  of  the  knee  have  contracted,  and  flexion 
of  the  knee  has  resulted,  and  the  foot  is  in  a  position  of  talipes 
equino-varus  or  simple  equinus.  In  other  -  cases  only  the  finer  move- 
ments of  the  hand  may  be  lost,  and  the  leg  movements  may  only 
be  impaired  enough  to  cause  a  bad  limp. 

Post-Hcuiiplcgic  Disorders  of  lilovcviciit. — In  certain  cases  of  hemi- 
plegia,  single    and   double,  a   disturbance   of   motion   occurs   at   a 

'  Forster;    Jahrbuch  f.  Khde.,  X.  F..  15,  261,  1880. 
-  Journ.  of  Nerv.  and  Mental  Dis.,  August,  1SS7. 


Fig.  580. — Post  Hemiplegic  Contraction  of  the  Arm 
in  the  Adult. 


582 


ORTHOPEDIC  SURGERY. 


later  stage,  which  is  spoken  of  under  many  different  names,  such  as 
athetosis  and  chorea  spastica;  while  what  is  called  "congenital 
chorea  "  in  many  cases  is  the  same  affection.'  The  very  great  vari- 
ety of  these  movements  can  be  seen  from  Greidenberg's  table,  in 
which  he  has  made  a  most  exhaustive  analysis  of  these  cases  as 
well  as  of  the  contractures. - 


Contractures 


Apoplectic 


Early, 
Late 


S  Clonic. 
Tonic. 
Intermitting. 
[  Muscular  rigidity. 
Paralytic,  passive,  temporary. 
Constant,  continuous,  fixed, 
changeable  (latent). 
Increased  tendon  reflexes. 
Associated  movements. 

f  Reflex — clonus. 
r^  ]  (  Tremor  proper. 

Essential  <   In  form  of  paralysis  agitans. 

(  In  form  of  disseminated  sclerosis. 
Constant. 

On  intended  movement — disturbance  of 
co-ordination  (hemiataxia). 


Hemichorea 
Athetosis. 


Mixed 
forms  in 
different 

com- 
binations. 


Gowers^has  described  a  characteristic  slow  mobile  spasm,  which 
he  speaks  of  as  "  mobile  spasm."  The  paper  of  Knapp'*  deals  in 
detail  with  the  character  of  these  movements. 

Symptoms  of  Spastic  Paralysis.— h.\.  times  the  tonic  spasm  of  the  leg 
muscles  becomes  so  much  the  most  prominent  feature  of  the  case  that 
it  is  spoken  of  as  spastic  paralysis  rather  than  as  hemiplegia.  .Spastic 
paralysis  is  a  condition  characterized  by  a  persistent  stiffness  and 
constant  spasm  of  the  muscles  of  the  legs  and  sometimes  of  the 
arms ;  the  legs  are  straight  and  rigid,  and  the  feet  are  extended, 
and  when  an  attempt  is  made  to  walk  the  child  stands  on  tiptoe, 
and  often  the  spasm  of  the  adductor  muscles  is  so  great  that  the 
legs  are  crossed.  The  walk  is  almost  characteristic,  a  clinging 
gait,  in  which  the  feet  are  scraped  along  the  floor  with  much  effort 
a'nd  straining  at  every  step,  if  indeed  the  spasm  is  not  so  great  that 
walking  at  all  is  out  of  the  question. 

The  distribution  of  the  paralysis  is  most  often  paraplegic  and 
sometimes  hemiplegic  or  even  monoplegic,  while  in  some  rarer 
cases  all  four  members  are  involved. 

In  general  this  affection  is  the  result  of  a  cerebral  lesion  and  a 
descending  degeneration  of  the  lateral  columns  of  the  spinal  cord. 
There  are,  however,  a  few  rare  cases  where  there  is  reason  to  be- 

^  Rau:    Neurol.  Centblatt.,  1887. 

^  Greidenberg:    Archiv  f.  Psychiatric,  xvii.,  131,  1886. 

3  Gowers:    "  Dis.  of  Nerv.  Syst. ,''  vol.  ii.,  p.  79. 

4  Knapp:   Bost.  Med.  and  Surg.  Journal,  Nov.  22d,  1888. 


CEREBRAL  J'AA'ALYS/S   1)1'    C/ff/.Dh'EN. 


583 


lieve  that  the  affection  may  be  primarily  spin  lI.  This  affection  has 
been  known  by  very  many  (Ufferent  names,  wiiich  should  be  men- 
tioned for  purposes  of  identification.  These  are  Little's  disease, 
tetanoid  pseudo-paraplegia,  spastic  spinal  paralysis,  permanent 
tetanus  of  the  extremities,  spastische  Gliederstarre,  double  hemi- 
plegia, etc. 

This  affection  is  in  the  majority  of  cases  congenital  or  caused 
at  birth,  and  represents  the  result  of  a  larger  brain  lesion  than 
takes  place  in  hemiplegia.  For  this 
reason,  these  children  are  for  the 
most  part  feeble-minded  or  idiotic  ; 
as  one  might  reasonably  expect  as 
the  result  of  so  extensive  a  brain 
lesion  occurring  at  so  early  an  age. 

With  four  exceptions  the  series 
reported  by  Osier  were  all  idiotic 
and  much  the  same  proportion  is 
noted  in  general ;  however,  one  not 
uncommonly  sees  children  of  more 
than  average  intelligence  affected 
with  spastic  paraplegia,  so  that  the 
existence  of  spastic  paralysis  is  by 
no  means  evidence  of  mental  inferi- 
ority. 

As  a  rule,  these  children  have 
strabismus,  a  stupid,  idiotic  face,  the 
saliva  drips  from  the  mouth  and  the 
teeth  decay  very  early.'  Most  often 
they  walk  in  tlie  manner  described, 
but  sometimes  the  muscular  spasm 
is  so  great  that  the  joints  are  so 
fixed  as  to  be  useless.  In  the  milder 
cases  the  difficulty  in  walking  lies  in 

the     fact     that    any  effort    to    use    the        Fio.  sS.-The  Gait  in  Spastic  Paraplegia. 

limbs  increases  the  muscular  spasm  and  tends  to  throw  the  let;  into 
the  position  of  extreme  adduction,  with  extension  of  the  foot  and 
generally  slight  flexion  of  the  knees  with  talipes  equinus.  It  is 
often  impossible  to  demonstrate  the  increased  tendon  reflexes  either 
at  the  knee  or  the  ankle  on  account  of  the  great  stiffness  of  the  legs, 
because  the  muscles  are  continually  at  their  maximum  of  contrac- 
tion. The  electrical  reaction  in  these  and  the  hemiplegia  cases  is 
unchanged.    There  is  no  atrophy  of  consequence  in  spastic  paralysis. 


'  Alice  Lollier:    "  De  I'etat  de  la  Dentition  chez  les  Enfants  idiots  et  arrieres,"  Paris, 


1887. 


584 


ORTHOPEDIC  SURGERY. 


The  standing  position  in  spastic  paralysis  is  shown  in  the  figure. 
In  this  case  the  spasm  was  so  great  that  the  patient  was  unable  to 
stand  alone.  When  supported,  the  thighs  were  adducted  very 
closely  and  the  toes  pointed  and  crossed  as  shown  in  the  illustra- 
tion. 

The  children  are  apt  to  be  uncleanly  in  their  habits  until  they 
have  reached  an  age  of  four  or  five  years  at  least.  The  mental 
disability  may  be  manifested  in  the  milder  cases  by  an  excessive 
irritability  and  a  disposition  to  do  mischief  and  perhaps  to  destroy 
playthings  wantonly.     Furious  outbursts  of  temper  are  not  uncom- 


FiG.  582.— Position  in  Attempting  to  Walk 
in  Severe  Spastic  Paralysis. 


Fig.  583. — Standing  Position  in  Spastic 
Paralysis. 


mon,  while  in  the  severer  cases  stupidity  is  the  most  prominent 
feature  and  all  the  characteristics  of  idiocy  are  in  many  cases 
plainly  developed. 

Conibinations  of  Hemiplegia  and  Spastic  Paralysis. — Single  hemi- 
plegia and  spastic  paralysis  of  both  legs  coexist  in  certain  cases, 
and  the  point  is  one  which  has  attracted  but  little  attention.  The 
occurrence  of  the  two  together  may  be  merely  a  coincidence  or  the 
spastic  paralysis  of  the  legs  may  be  a  sequel  of  the  hemiplegia.  If 
spastic  paralysis  is  likely  to  follow  hemiplegia  as  one  of  its  sequelae, 
this  should  be  borne  in  mind  in  speaking  of  the  prognosis  of  the 
latter. 


CKRIUiKAL  PA  Ryl  LYSIS   Ol'  CI  1 1  f.l )  R  EN.  585 

The  cases  of  cerebral  i)aralysis  in  the  ('hihh'en's  Jlospital  series 
were  analyzed  with  re^^ard  to  this  question.  There  were  twenty- 
six  hemiplegia  cases  and  in  nine  of  these  [)atients  spastic  paralysis 
of  both  legs  was  also  present.  The  following  calculation  makes  it 
appear  that  s[)astic  paraplegia  is  at  times  a  sequel  of  single  hemi- 
plegia. 

In  the  17  cases  where  hemiplegia  alone  existed,  the  average 
duration  of  the  paralysis  at  the  time  of  observation  had  been  5.8 
years;  but  in  the  9  cases  where  spastic  paralysis  was  also  present 
the  average  duration  had  been  5.9  years,  or  more  than  two  years 
longer.  It  would  seem  from  this  that  spastic  paralysis  co-existed 
with  hemiplegia  in  cases  of  longer  standing  than  when  hemiplegia 
was  found  alone.  Moreover,  what  appear  to  be  transition  cases 
from  simple  hemiplegia  to  severe  spastic  paralysis  were  present. 
Two  of  the  children,  aged  4  and  14  respectively,  had  hemiplegia 
which  presented  the  usual  signs,  but  they  had  also  exaggerated 
tendon  reflexes  of  both  legs,  they  walked  with  something  of  the 
clinging  gait  that  distinguishes  spastic  paralysis,  and  they  were 
unsteady  on  their  feet,  and  one  of  them  has  lately  become  worse. 
Possibly  they  will  never  go  on  to  any  more  serious  condition  than 
this,  but  the  other  7  cases  present  fully  marked  signs  of  spastic 
paralysis  with  those  of  hemiplegia. 

It  seems,  therefore,  as  if  it  were  not  impossible  that  spastic  par- 
alysis of  the  legs  was  occasionally  a  sequel  of  simple  hemiplegia 
coming  on  after  some  years. 

Spastic  Paralysis  of  Spinal  Origin. —  In  certain  cases  the  symp- 
toms of  spastic  paralysis  of  the  legs  are  found  without  any  traces 
of  hemiplegia  or  any  cerebral  symptoms,  and  some  of  these  para- 
plegic cases  have  every  appearance  of  being  primarily  spinal  in 
origin,  but  as  yet  no  pathological  basis  for  this  belief  exists,  and  it 
can  only  be  regarded  as  a  similar  affection  to  primary  lateral  sclerosis 
in  the  adult.  Most  writers  pass  it  over  in  silence,  but  Eichhorst 
speaks  of  it  as  occurring  in  children  and  attributes  it  to  syphilis  or 
consanguineous  marriages.  Cases  have  been  reported  from  time  to 
time,  especially  by  Seeligmiiller,'  and  a  very  few  cases  have  been 
seen  by  the  writers  where  it  was  impossible  to  find  any  symptoms 
referable  to  a  cerebral  origin. 

Symptoms  of  Incoordination  or  Idiocy. — The  last  of  the  three  classes 
into  which  these  cases  of  cerebral  paralysis  were  divided  represents 
at  best  a  miscellaneous  collection.  Their  only  excuse  for  appear- 
ing here  is  the  very  close  outward  resemblance  that  they  present 
on  superficial  examination  to  the  hemiplegic  and  spastic  cases 
already  considered;  but  definite  paralysis  and  spastic  rigidity  of 
'  Deutsch.  Med.  Wochschft.,  1S76,  Nos.  16  and  17. 


586 


ORTHOPEDIC  SURGERY. 


the  muscles  are  absent,  and  idiocy  obscures  everything.  If  they 
are  seen  seated,  the  stupid  cross-eyed  look,  the  drooping  head  and 
the  drooling,  are  exactly  what  is  seen  in  the  severe  mental  enfeeble- 
ment  of  spastic  paralysis  or  hemiplegia.  But  put  the  child  on  his 
feet  and  the  difference  is  at  once  evident.  Either  his  muscles  are 
so  lax  that  he  will  be  unable  to  bear  his  weight  at  all,  or  he  will 
stand  holding  his  parent's  hands  with  his  feet  wide  apart,  his  knees 
bant,  and  his  trunk  leaning  forward.  The  whole  body  sways  to 
and  fro  with  an  oscillating  movement,  and  the  sense  of  equilibrium 
seems  almost  wanting;    if  he  is  let  alone,  he  Avalks  in  a  staggering 

uncertain  way,  with  many 
falls.  From  this  the  con- 
dition grades  ol^  to  a  dis- 
ability so  great  that  the 
child  cannot  even  sit  up; 
when  it  is  propped  up  the 
head  lops  on  to  one  shoul- 
der, the  vertebral  column 
fails  to  support  the  trunk 
and  bends  to  a  marked  de- 
gree, and  every  muscle 
seems  limp  and  useless. 
There  is  no  suspicion  of 
muscular  rigidity  or  local- 
ized paralysis. 

Sensory  disturbances  are 
not  uncommon,  and  often 
a  pin  can  be  thrust  through 
the  skin  without  pain. 
Nearly  all  these  children 
have  strabismus,  often  with 
a  large  head  and  prow-shaped  forehead.  The  reflexes  are  some- 
times normal,  and  sometimes  increased,  while  the  legs  are  generally 
flabby  and  cool,  and  often  the  hands  and  feet  undeveloped.  Every 
grade  of  the  condition  is  seen  from  that  described  above  to  com- 
plete helplessness. 

Etiology. — The  consideration  of  the  etiology  of  these  three  groups 
can  best  be  taken  up  under  one  head. 

The  first  point  of  interest  in  the  consideration  of  the  etiology  of 
these  cases  of  cerebral  paralysis  lies  in  the  question  of  whether 
they  were  born  after  a  hard  or  an  easy  labor.  Mr.  Little,  of  Lon- 
don was  the  first  to  call  attention  to  the  association  of  difficult 
labor  and  spastic  paralysis,  and  in  1862  appeared  his  paper,  which 
has  become  classical,  "  On  the  hifluence  of  Abnormal  Parturition, 


Fig.  584. — Attitude  in  Idiocy. 


Cl'.KI'HUsAI.   I'.INAI.VSIS   (>/•    CI  1 1 1 .1  >  h' EN.  587 

etc.,  upon  the  future  Mental  and  IMiysical  (>>n(lition  of  the  Child," 
hi  which  he  tabulated  sonie  63  cases  of  spastic  paralysis  and  hemi- 
plegia, in  all  of  which  he  found  that  it  was  due  to  difficult  labor. 
Ross,  twenty  years  later,  elaborated  the  point  somewhat  more 
fully,  and  quoted  authorities  to  show  the  liability  of  the  new-born 
to  meningeal  hemorrhage.  Weber  made  161  autopsies  of  new- 
born children,  and  in  81  cases  where  the  spinal  canal  and  head  were 
opened,  33  times  there  was  extravasation  of  blood  from  the  spinal 
and  cerebral  meninges.  Of  64  cases  of  foot  extractions  examined 
by  Ruge  there  was  rupture  of  the  vertebral  column  in  8. 

The  influence  of  difificult  labor  as  a  cause  of  cerebral  paralysis 
seems  to  have  been  somewhat  overestimated.  Of  Mr.  Little's  cases 
a  large  proportion  are  abnormal  only  in  the  occurrence  of  phe- 
nomena which  are  of  little  interest,  e.g.,  three  cases  are  considered 
abnormal  because  the  cord  was  wound  around  the  child's  neck. 
In  the  33  cases  of  cerebral  paralysis  where  the  labor  was  noted  in 
the  Children's  Hospital  series,  17  were  born  by  an  easy  labor  ac- 
cording to  the  mother's  own  account.  In  the  class  of  feeble-minded 
children  in  general,  Dr.  Langdon  Down  says  :'  "  I  found  that  among 
the  great  number  of  feebled-minded  children  about  whom  I  could 
get  thoroughly  reliable  accounts,  in  only  3  per  cent  had  the  forceps 
or  any  other  instrument  been  used,"  and  he  also  quotes  the  late 
Dr.  Ramsbotham  as  telling  him  "  that  the  cases  were  very  few  in 
which  he  could  trace  any  cerebral  lesion  as  resulting  from  the 
employment  of  the  forceps." 

The  forceps,  however,  occasionally  cause  so  serious  an  injury 
that  a  depression  of  the  skull  is  noted  years  afterward  on  the  side 
opposite  to  the  hemiplegia. 

There  were  two  cases  of  hemiplegia  in  the  Children's  Hospital 
series  where  a  depression  in  the  skull  was  evident  4  and  8  years 
after  the  beginning  of  the  paralysis.  Gaudard  met  with  no  obser- 
vation of  the  kind,  and  Wallenburg,  in  his  160  cases,  assigned  diffi- 
cult labor  as  a  cause  in  only  6  cases  and  does  not  mention  injury 
from  the  use  of  forceps.-  * 

A  large  number  of  these  children  are  born  prematurely,  as  in  28 
out  of  49  of  Little's  cases,  and  at  other  times  asphyxia  neonatorum 
seems  to  be  the  active  cause.^  In  general  it  may  be  said  that  ab- 
normal labor,  though  a  common  cause,  is  b}^  no  means  the  universal 
one  that  some  writers  would  have  us  believe. 

'  "  Mental  Affections  of  Childhood  and  Youth,"  London,   1SS7,  p.  44. 

=  Phil.  Med.  News,  1887,  ii.  Paper  by  Dr.  Parvin:  American  Journ.  Med.  Sci., 
1875;    Sinkler:    Med.  News,    1885,  vol.  i. 

3  McNutt:  Am.  Journ.  of  Obst.,  18S5;  Parrot:  Clinique  des  Xouveau-nes.  Paris, 
1877. 


588  ORTHOPEDIC  SURGERY. 

Premature  labor  is  another  condition  which  has  not  received 
due  attention  as  a  causative  factor.  Very  many  of  these  children 
are  born  by  unusually  rapid  and  easy  labors. 

With,  regard  to  causes  affecting  the  child  in  pregnancy,  the  ten- 
dency of  the- parents  is  to  assign  it  to  any  cause  rather  than  inheri- 
tance. Dr.  Down  says  of  this  tendency,  "  Parents  always  prefer  to 
refer  the  cause  to  a  post-uterine  or  non-congenital  origin,  partly 
because  they  think  it  frees  them  from  a  suspicion  of  hereditary  in- 
fluence, and  partly  from  a  notion  that  the  child  is  more  likely  to 
be  restored  to  its  pristine  state,"  and  so  this  tendency  of  referring 
it  to  frights,  etc.,  in  pregnancy,  arises. 

Mitchell '  tabulated  the  cases  of  443  idiots  that  he  saw  consecu- 
tively, with  regard  to  this,  and  found  only  28  cases  where  there 
was  any  likelihood  of  its  having  been  due  to  a  fright  or  strong 
mental  emotion  during  pregnancy,  and  in  general  he  found  this  to 
be  his  experience  in  the  examination  of  some  1,500  idiots  and  im- 
beciles. Practically  it  can  be  noticed  in  many  cases  that  the 
parents  of  these  children  are  distinctly  neurotic,  perhaps  even  epi- 
leptic. Drunkenness  in  the  parents  at  other  times  seems  to  stand 
in  a  causative  relation  to  spastic  paralysis. 

Trauma  sometimes  is  clearly  to  be  assigned  as  the  cause  of  cere- 
bral paralysis,  as  in  a  case  where  a  child  fell  36  feet  at  the  age  of 
18  months  and  developed  spastic  paralysis."" 

Infectious  Diseases. — Some  60  or  more  cases  have  been  reported 
where  cerebral  paralysis  has  come  on  in  the  course  of  or  directly 
after  some  infectious  disease.  Such  cases  have  been  reported  after 
measles,  scarlet  fever,  typhoid,  mumps,  pertussis,  diphtheria,  vacci- 
nation, dysentery,  meningitis,  and  typhus  fever.^ 

Syphilis  is  undoubtedly  a  cause,  although  no  very  definite  infor- 
mation has  yet  been  given  about  its  frequency  or  the  conditions 
under  which  it  produces  cerebral  paralysis.'* 

In  a  large  number  of  cases  the  disease  seems  to  affect  perfectly 
healthy  children  without  any  assignable  cause.  The  indigestion 
attacks,  the  fever,  and  the  convulsions  attending  the  onset  cannot 
fairly  be  assigned  as  causes.  The  disease  is  about  evenly  divided 
betAveen  the  sexes. 

'  Obstet.  Trans.,  London,  vol.  xxvi. 

^  Boston  Med.  and  Surg.  Journal,  June  28th,  1888;  see  also  3  cases  similar  in  Osier's 
Series. 

3  Wallenburg,  Gowers,  and  Gaudard:  Loc.  cit.;  Marie:  Prog.  Med.,  No.  36; 
Richardiere:  "Etude  sur  le  Sclerose  Enceph.  de  I'Enf.,"  etc.,  These  de  Paris;  Jendrassik 
and  Marie:  Arch,  de  Phys.  Nouv.  et  Path.,  v.,  51,  1885;  Osier:  Phila.  Med.  News, 
July  14th,  1888. 

4  Abercrombie:   St.  Earth.  Rep.,  xvi.,  p.  35,  and  Brit.  Med.  Journ.,  June  i8th,  1887. 


Cl'lRIiHRAL  PARALYSIS   OF   CHILDREN.  589 


I'A'l  ll()I,()(;V. 

The  pathological  condition  is-  much  the  same  in  hemiplegia  and 
in  spastic  paralysis.  These  conditions  in  general  are  due  to  the 
destruction  of  brain  tissue  by  embolism  or  hemorrhage,  and  the 
resulting  retardation  of  growth  of  the  affected  portion  of  the  brain, 
together  with  the  secondary  changes  in  the  spinal  cord. 

Recent  autopsies  on  these  cases  are  few,  and  on  account  f^f  the 
recent  recognition  of  the  affection,  the  pathological  data  are  scanty. 
In  the  seventeen  early  autopsies  '  there  were  seven  cases  of  plug- 
ging of  the  artery  of  Sylvius,  and  nine  cases  of  hemorrhage  of  prac- 
tically the  adult  type.  The  case  of  Ruhcmann  showed  a  translu- 
cent patch  suggesting  a  primary  local  inflammation.  The  case  is 
unique. 

Autopsies  made  later  in  the  disease  show  pathological  changes 
which  are  more  extensive  and  less  definite  in  their  character. 
Wasting  and  sclerosis  of  a  greater  or  less  part  of  the  brain  and  the 
condition  known  as  porencephalus  are  what  one  finds  in  these  later 
cases.  These  seem  to  be  the  late  results  of  the  destructive  change 
mentioned  above,  which  have  occurred  in  a  growing  brain  and  have 
retarded  its  growth  and  have  produced  an  extensive  scar  formation 
in  the  place  of  cerebral  tissue. 

Porencephalus  occurs  as  a  loss  of  substance  in  the  form  of  cavi- 
ties or  cysts,  situated  at  the  surface  of  the  brain  and  going  more 
or  less  deeply  into ;  it  is  in  all  cases  the  motor  region  which  is 
affected.  This  condition  of  porencephalus  may  be  of  greater  or 
less  extent  and  unilateral  or  bilateral.  If  either  porencephalus  or 
sclerosis  is  unilateral,  hemiplegia  results;  if  the  lesion  be  bilateral, 
double  hemiplegia  or  spastic  paraplegia  is  the  clinical  manifesta- 
tion. These  lesions  represent  merely  the  late  stages  of  a  process 
originally  a  hemorrhage,  an  embolism,  or  a  localized  encephalitis. 
There  are  64  autopsies  reported  in  cases  of  atrophy  and  sclerosis, 
and  53  where  porencephalous  defect  on  one  or  both  sides  was 
present.^ 

^  Recent  Autopsies. — Gibb:  Lancet,  1858. — Vernois  and  Valleix:  Quoted  by  Lewis 
Smith:  "  Dis.  of  Children,"  4th,  ed. — Wrany  Neuretter:  Quoted  by  Wallenburg. — Tay- 
lor: Brit.  Med.  Journal,  1880. — Callender:  St.  Barth.  Hosp.  Reps.,  vol.  v. — KeRy  John- 
son: Med.  Times  and  Gaz.,  1880. — Barlow  :  Brit.  Med.  Journ.,  1876. — Lewkowitsch: 
Quoted  by  Wallenburg. — Abercrombie:  Brit.  Med.  Journ.,  1887,  vol.  i. — Osier:  Canada 
Med.  and  Surg.  Journ.,  1886. — Dulles:  Phila.  Med.  Times,  vol.  vi. — Ruhemann:  Cent, 
f.  Klin.  Med.,  1887,  No.  48.— Reimer:    Jahrb.  f.  Khde.,  N.  F.,  2,  1877,  70. 

^  Other  Autopsies. — Little:  Obstet.  Transactions,  1S62. — Kundrat:  "Die  Poren- 
cephalic," 1882. — Henoch:  "Dis.  of  Children,"  Am.  ed.,  1882. — Heubner:  Berlin,  klin. 
Woch.,  1882. — Ross:    Brain,  vol.  v. — McNutt  (with  table  of  Autopsies):  Am.  J.  M.  Sci., 


590 


ORTHOPEDIC  SURGERY. 


The  cerebral  origin  of  spastic  paralysis  is  admitted  by  the  lead- 
ing neurologists,  pure  spinal  spastic  paralysis  being  considered  ex- 
cessively rare.' 

Pathological  evidence  as  to  the  existence  of  primary  lateral 
sclerosis  (spinal  spastic  paralysis)  in  the  child  is  wanting,  but  the 
clinical  evidence  in  favor  of  its  occasional  existence  is  very  strong, 
as  has  already  been  pointed  out. 

The  pathology  of  the  condition  is,  in  short,  a  lesion  of  the  motor 
tract  of  the  brain  with  consequent  atrophy  and  retarded  develop- 
ment of  the  affected  portion,  and  descending  degeneration  of  the 
pyramidal  tracts  and  lateral  columns  of  the  cord ;  from  the  exten- 
sive atrophy  found  in  young  children  at  autopsy,  it  seems  that  un- 
questionably sometimes  the  disease  originates  in  defective  develop- 
ment of  the  nervous  centres,  especially  the  pyramidal  tracts,^  rather 
than  in  an  acute  cerebral  hemorrhage  or  embolism. 

The  co-existence  of  spastic  paraplegia  and  hemiplegia  in  the 
adult  has  not  escaped  attention.  Hadden^  has  written  about  it, 
and  accounts  for  its  occurrence  by  the  presence  of  an  unusual 
decussation  of  the  pyramidal  tract  fibres.  Charcot,  on  the  other 
hand,  thinks  it  due  to  a  second  decussation  of  the  motor  fibres  in 
the  dorsal  region. 

Striimpell-*  has  propounded  a  theory  that  most  cerebral  paralysis 
is  due  to  a  local  inflammation  of  the  cells  of  the  brain  cortex, 
analogous  to  the  inflammation  of  the  cells  in  the  anterior  cornua  of 
the  cord  in  infantile  paralysis.  It  can  only  be  said  that  the  theory, 
however  plausible,  lacks  anatomical  proof;  even  Kast,  its  latest 
advocate,  admits  that.  Unless  the  recent  case  of  Ruhemann  be 
accepted  as  poliencephalitis,  there  is  nothing  resembling  a  primary 
local  encephalitis  in  any  of  the  autopsies  made  early  in  the  disease, 
and  the  atrophy  found  in  the  later  ones  is  perfectly  well  explained 
by  the  occurrence  of  such  well-known  primary  processes  as  embol- 

1885. — Richardiere:  Loc.  cit. — Isambert  and  Robin:  (Wuillamier:  "  Sur  I'Epilepsie  dans 
THemiplegie  Infantile,"  Paris,  1882). — Bourneville  and  Blackey:  Quoted  by  Wuillamier. 
— Simon:  Rev.  Mens,  des  Mai.  de  I'enfance,  tomes  i.  and  ii. — Ashby:  Brit.  Med.  Journ., 
1S86,  i. — Moore:  St.  Earth.  Rep.,  xv. — Gee:  St.  Barth.  Rep.,  xvi. — Mierjewsky:  Arch. 
de  Neurol.,  tome  i. — Forster:  Jhrb.  f.  Khde.,  xv. — Seeligmliller:  fhrb.  f.  Khde.,  N.  F., 
xiii.,  p.  760. — Wallenburg:  (Tables). — Kast:  Arch.  f.  Psych.,  1887,  18,  280.— Otto: 
Arch.  f.  Psych.,  xvi.,  215. — Knapp:  Loc.  cit. — Neaf:  "  Die  spast.  sp.  Paralyse  im  Kin- 
desalter,"  Inaug.  Diss.,  Zurich,  1885. 

'  Catsaras:  Ann.  Med.  Psychol.,  July,  1887;  Ross:  Loc.  cit.;  McNutt:  Am.  Journ. 
Med.  Sci.,  Apr.,  1888,  9,  58;  Neaf:  "  Die  spast.  spin.  Paralyse  im  Kindesalter,"  Inaug. 
Diss.,  Zurich,  1885. 

^  Archiv  f.  Psych.,  Bd.  xvii. ;  Archives  de  Physiol.,  3d  Serie,  tome  iv.,  1884;  Sharkey: 
Quoted  by  Osier,  loc.  cit.,  p.  143;    Blocq:    "  Les  Contractures,"  Paris,    1888. 

3  Iladden:    St.  Thomas'  Hosp.  Rep.,  1882,  61. 

4  Striimpell:    Jhrb.  f.  Khde.,  N.  F.,  xxii.,  1874,  p.  173. 


CKRKHKAL  PARALYSIS   OF   CJ/ / /.DA'KN.  591 

ism,  hcmorrlia^rc,  thrombosis,  as  Gowcrs  suggests,  and  defective 
development. 

Osier'  sums  up  the  possible  causes  of  infantile  hemiplegia  as 
follows : 

(i)  Hemorrhage  occurring  during  violent  convulsions  or  during 
a  paroxysm  of  whooping  cough''  (or  at  birth j. 

(2)  Post-febrile  processes,  (a)  embolic,'  (b)  cndo-  and  peri-arterial 
changes,"*  {c)  encephalitis. 

(3)  Thrombosis  of  cerebral  veins. ^ 

There  seems  reason  to  believe  that  all  of  these  causes  at  times 
have  an  influence  singly  or  together  in  producing  cerebral  paraly- 
sis.    The  commonest  are  undoubtedly  hemorrhage  and  embolism. 

To  enter  upon  a  discussion  of  the  pathological  condition  in  the 
cases  of  incoordination  spoken  of  above,  would  be  to  introduce  the 
very  extensive  subject  of  the  pathology  of  idiocy.  Suffice  it  to 
say  that  all  sorts  of  malformations  of  the  skull  and  brain  have  been 
recorded,  hypertrophy  and  atrophy"  of  the  brain  tissue  have  been 
described,'  while  localized  and  disseminated  sclerosis,"*  chronic  hy- 
drocephalus,' and  pressure  from  meningitis  '°  are  among  the  other 
causes. 

Diagnosis. 

The  diagnostic  signs  of  hemiplegia  in  the  child  are  as  follows :  a 
motor  paralysis  of  one  or  rarely  both  sides  of  the  body  and  often 
one  side  of  the  face,  followed  by  atrophy  of  the  paralyzed  mus- 
cles, while  no  loss  of  sensation  is  present.  The  reflexes  of  the 
affected  side  are  much  increased  and  mental  impairment  is  com- 
mon. 

Spastic  paralysis  is  characterized  by  tonic  contraction  of  the 
muscles  which  yields  to  steady  resistance.  It  is  frequently  associ- 
ated with  mental  enfeeblement.  The  reflexes  are  increased  and 
the  galvanic  reaction  is  normal.  At  times  the  muscular  rigidity 
is  so  excessive  that  the  exaggerated  knee-jerk  and  ankle  clonus 
cannot  be  obtained.  In  estimating  the  child's  mental  condition, 
no  weight  whatever  can  attached  to  the  parents'  account  of  the 
patient's  capacity. 

'Osier:  Med.  News,  Phila.,  Aug.  nth,  1S88,  p.  143. 
=  West:    London  Med.  Press,  and  Circ,  1887. 

3  Landouzy  and  Siredey:   Rev.  de  Med.,  1885. 

4  Jendrassik  and  Marie:    Arch,  ftir  Phys. ,  1885. 

5  Gowers  and  Handford:    Brit.  Med.  Journal,  1887,  i.,  1098. 

*  Cotard:    These  de  Paris,  1868;    Seibert:  Arch.  f.  Pediatrics,  March.  iSSS,  168. 

7  Beach:    Am.  Jour.  Ment.  Sci.,  June,  1SS3,  and  April,  iSSi. 

®  Bunhuer:    Arch.  f.  Psych.,  xii.,  3. 

9  Tambarini:    Revist.  Sperim.,  vi.,  285. 

'°  Seibert:  Log.  cit. 


592 


OR  THOPEDIC  S  UK  GER  V. 


Differential  Diagnosis. 


The  differentiation  of  cerebral  paralysis  and  infantile  spinal  par- 
alysis has  been  dealt  with  at  length  in  the  preceding  chapter. 

Obstetrical  paralysis'-  might  be  mistaken  for  cerebral  lesions,  but 
a  careful  examination  would  determine  the  paralysis  to  be  limited 
to  the  distribution  of  some  especial  nerve.-  It  is  commonest  in 
the  "distribution  of  the  facial  nerve  after  the  use  of  the  forceps,  but 
it  may  occur  in  one  of  the  extremities  in  consequence  of  the 
stretching  of  the  nerve  trunks  in  the  manual  extraction  of  the 
child's  body.  The  duration  of  obstetrical  paralysis  is  short  and  the 
cause  is  evident.^ 

Cerebral  titinors  may  cause  the  symptoms  of  hemiplegia,  and  a 
diagnosis  of  this  condition  from  the  lesions  generally  causing  par- 
alysis would  ordinarily  be  impossible.  Such  cases  are  the  well- 
known  case  of  brain  tuberculosis  reported  by  Seeligmiiller  ■'  and  a 
case  of  glioma  reported  by  Osler.^  Tumors  of  the  pons  or  cere- 
bellum would  cause  symptoms  of  bilateral  ligidity  (spastic  para- 
plegia) if  they  compressed  the  motor  tracts.  Such  tumors  are 
reported  by  Sharkey.*^ 

Spastic  paralysis  of  both  legs  is  not  likely  to  be  mistaken  for 
anything  else  when  well  developed.  When  existing  in  a  slight 
degree  it  is  difificult  to  say  whether  it  is  spastic  paralysis  or  begin- 
ning pseudo-hypertrophic  paralysis;  the  stiff  uncertain  walk  is 
somewhat  similar.  In  spastic  paralysis  the  spasm  in  the  legs  may 
be  very  slight  and  the  reflexes  are  perhaps  not  enough  increased  to 
establish  the  existence  of  cerebral  disease.  Such  cases  sometimes 
occur  and  time  can  alone  settle  the  diagnosis.  French  authors' 
describe  an  idiopathic  muscular  contraction  following  rickets  or 
other  prolonged  illness,  and  Osier  saw  a  rickety  child  where  such 
spasm  existed.  But  in  general  most  of  the  French  cases  seem  to 
have  been  due  to  cerebral  disease.  It  is  described  as  being  ordi- 
narily confined  to  the  arms  and  as  be'ing  painful  and  intermittent. 
The  writers  have  never  seen  such  cases. 

The  cases  of  spastic  paralysis  which-  are  brought  to  the  ortho- 
pedic surgeon  are  usually  those  of  the  type  in  which  distortion  of 
the  limbs  and  inability  to  walk  are  prominent  symptoms. 

'  Duchenne:    "  Traite  de  1' Electrization  Localisee,"  3d  ed. 

=  Nadaud:    "  Des  Par.  Obstetricales  des  Nouveau-Nes,"  Paris,  1872. 

3  Budin:   Le  Bulletin  Medical,  No.  20,  1888. 

4  Seeligmiiller:    Jhrb.  f.  Khde.,  Bd.  xiii. 
s  Osier:    Am.  Journ.  Med.  Sci.,  1885. 

^  Sharkey:    "  Spasm  in  Chronic  Nerve  Disease,"  London,  1886. 

7  Onimus:  Rev.  Mens,  des  Mai.  de  I'Enfance,  1883;  Lannois:  France Medicale,  1884;; 
Limard:    These  de  Paris,  1SS4,  No.  85. 


ClLKEIlRylL   I'ARAD'SIS    Of'    (  I H 1 .1  )h' I'lN.  593 

The  distortion  is  characteristic.  'J'iie  feet  arc  held  in  a  position 
of  equinus,  the  Hnibs  are  sometimes  crossed,  and  the  knees  slightly 
bent.  These  distortions  are  exac^crcrated  when  the  chih.i  attempts 
to  walk,  but  on  manipukition  under  gradual  force  the  deformities 
can  be  overcome,  and  the  hmb  put  in  a  normal  position,  but  the 
distortion  recurs  immediately  as  resistant  as  ever;  thus  differing 
from  the  deformities  in  infantile  paralysis,  which  are  hrndy  resistant, 
but  when  overcome  do  not  immediately  recur. 

There  is  no  diagnostic  criterion  by  which  the  recognition  of 
these  miscellaneous  cases  of  idiocy  or  incoordination  may  be  surely 
made,  so  that  the  diagnosis  of  incoordination  or  idiocy  is  often  at- 
tended with  much  difficulty,  especially  in  young  children,  where 
inability  to  walk  is  the  only  definite  symptom.  Such  a  condition 
may  result  from  rickets,  from  feebleness,  from  simple  backward- 
ness, and  sometimes  from  paralysis  due  to  unnoticed  Pott's  disease. 
Under  these  circumstances  one  would  give  much  weight  in  the 
diagnosis  of  idiocy  to  the  child's  expression,  the  size  of  the  head 
(hydrocephalus  is  so  often  associated  with  this  incoordination),  the 
presence  of  strabismus,  and  especially  an  oscillating,  rhythmical 
movement  of  the  head  or  whole  body  should  be  looked  for  as 
pointing  to  some  cerebral  insufficiency.  Later  in  life  the  condition 
is  only  too  apparent. 

Prognosis. 

The  prognosis  in  these  cases  should  be  most  guarded.  In  hemi- 
plegia there  are  two  favorable  things  to  be  said,  the  child  will 
probably  live  and  the  paralysis  will  undoubtedly  improve  some- 
what. The  unfavorable  things  which  are  to  be  feared,  in  general, 
are  more  likely  to  come  in  the  earlier  cases  of  paralysis  than  in 
those  that  occur  later  in  life.  These  are:  mental  enfeeblement,  a 
certain  amount  of  deformity  from  retarded  growth  of  the  paralyzed 
side,  and  epilepsy  in  about  half  the  cases,  perhaps  not  making  its 
appearance  until  the  age  of  puberty.  The  development  of  post- 
hemiplegic movements  is  a  bad  prognostic  sign,  inasmuch  as  such 
cases  are  most  likely  to  develop  epilepsy. 

Finally  spastic  paralysis  of  both  legs  is  to  be  feared  as  a  later 
sequel  to  the  hemiplegia. 

It  will  be  seen,  therefore,  that  cerebral  hemiplegia  in  childhood 
is  a  very  grave  affection,  that  recovery  is  not  likely  to  be  complete 
in  the  paralyzed  limbs,  and  that  very  serious  sequelae  may  follow 
at  any  time. 

On  the  other  hand,  in  many  instances  where  complete  helpless- 
ness seems  inevitable  in  infancy,  marked  improvement  to  a  condi- 
tion of  comparative  activity  is  sometimes  noticed. 
38 


594  ORTHOPEDIC  SURGERY. 

With  regard  to  spastic  paraplegia  it  is  safe  to  assert  in  most 
cases  that  the  child  will  improve  in  the  use  of  the  legs;  most  chil- 
dren learn  to  walk  at  the  age  of  five  or  six  and  to  talk  imperfectly. 
Recovery  is  of  course  out  of  the  question,  but  the  general  tendency 
is  toward  improvement  in  walking  and  talking  for  many  years, 
although  it  must  be  borne  in  mind  that  the  final  result  in  well- 
marked  cases  can  never  be  other  than  distressing.  Mental  en- 
feeblement  is  generally  present  from  the  first,  when  it  is  present  at 
all,  but  it  may  become  much  more  evident  as  the  years  go  on  and 
the  demands  upon  the  intellect  become  more  complicated  and  ex- 
acting. 

The  general  resistance  of  such  children  is  not  very  good,  they  are 
more  liable  than  other  children  to  fall  victims  to  general  diseases, 
and  their  inability  to  go  about  freely  renders  them  more  suscepti- 
ble to  illness.  As  a  rule,  they  are  not  long  lived,  but  there  is  no 
immediate  liability  to  any  especial  disease,  simply  a  slightly  im- 
paired vitality.  No  question  is  more  often  asked  than  this  one 
about  the  child's  prospect  of  long  life. 

The  cases  of  incoordination  or  idiocy  do  not  show  any  tendency 
to  spontaneous  improvement.  Sometimes  they  improve,  and  some- 
times they  grow  worse,  but  oftenest  they  seem  to  remain  in  very 
much  the  same  condition.  It  is  the  experience  of  the  writers  that 
all  cases  of  cerebral  paralysis  are  particularly  liable  to  fatal  menin- 
gitis. 

Treatment, 

During  the  onset  of  the  disease,  in  those  rare  cases  where  the 
diagnosis  of  a  destructive  cerebral  lesion  is  made  so  early,  the 
treatment  should  be  the  same  that  is  ordinarily  advisable  in  any 
convulsive  attack.  Immersion  of  the  body  in  hot  water  and  cold 
applications  to  the  head,  followed  by  leeches  behind  the  ears  and 
an  ice  cap  to  the  head,  bromides  and  chloral,  free  catharsis  and 
absolute  rest  with  the  head  raised ;  all  of  which  measures  are  of 
course  intended  to  limit  as  far  as  possible  the  extent  of  the  brain 
injury,  having  in  mind  the  fact  that  the  harm  is  done  by  a  destruc- 
tion of  brain  tissue,  generally  due  to  an  effusion  of  blood  into  the 
brain  substance,  and  any  measures  which  tend  to  lower  the  circu- 
lation in  the  brain  will  retard  as  far  as  may  be  the  harm  done  by 
the  hemorrhagic  process. 

In  the  great  majority  of  cases  the  nature  of  the  trouble  is  not 
recognized  until  the  acute  symptoms  have  passed  off  and  the  par- 
alysis has  become  well  established.  As  in  anterior  polio-myelitis 
the  structural  harm  has  been  done  and  no  treatment  addressed  to 


lJ':i<j<:i:nal  /'aa'^u^vs/s  (>/■'  <////./)AKN. 


595 


the  centres  can  accomplisli  very  iiiiuli.  Tin;  aim  must  he  Ut  keep 
as  far  as  possible  the  i^aralyzed  h'mb  from  trophic  changes  and  to 
stimulate  the  muscles  to  recover  as  far  as  p(;ssible  by  carefully 
caring  for  their  condition.  For  these  reasons  such  measures  as 
galvanization  of  the  head  have  been  denounced  by  J^ernhardt  and 
Gaudard,  although  advocated  by  some  writers.  The  proper  use 
of  electricity  is  in  its  stimulatit^n  of  the  muscles,  and  such  children 
should  receive  four  or  five  applications  each  week  of  the  faradic 
current,  and  each  sitting  should  be  ten  or  fifteen  minutes  in  length. 
Undoubtedly  benefit  results  from  a  careful  course  of  this  treatment, 
but  it  must  be  long  continued  and  it  is  not  essential  to  improve- 
ment, for  many  cases  do  perfectly  well  without  any  use  of  electric- 
ity. Galvanism  of  the  spine  with  an  ascending  or  descending  cur- 
rent is  deemed  of  use  in  cases  of  spastic  paralysis. 

Of  equal  or  greater  importance-  is  a  systematic  and  persistent 
course  of  rubbing  and  manipulation  of  the  paralyzed  limbs.  In 
spastic  paralysis,  persistent  manipulations  with  strong  flexion  and 
extension  of  the  diseased  limbs  may  prove  of  great  benefit  in  pre- 
venting a  disabling  rigidity  and  in  maintaining  a  healthy  condition 
of  the  muscles. 

In  detail  such  manipulation  should  be  of  the  same  character  as 
that  described  under  infantile  paralysis;  except  that  the  knees  and 
hips  should  be  forcibly  flexed  several  times  and  the  feet  bent  up 
beyond  a  right  angle  if  any  reasonable  degree  of  force  will  accom- 
plish it. 

In  spastic  paralysis  it  is  at  times  possible  to  accomplish  much  by 
muscular  training  and  exercise.  More  could  be  done  in  this  way 
were  it  not  for  the  mental  inability  of  so  many  of  these  patients, 
which  makes  it  impossible  for  them  to  cooperate  to  any  extent  in 
such  treatment.  But  in  those  uncommon  cases  where  the  mind  is 
bright  and  active,  the  patient  can  be  trained  to  use  the  limbs  to 
much  better  advantage  than  he  has  been  doing,  just  as  a  person 
who  stutters  can  be  improved  by  systematic  and  repeated  exercises. 
The  muscles  which  are  most  strongly  contracted  are  the  thigh 
adductors  and  the  calf  muscles.  Such  a  patient  should  be  given 
exercises  calculated  to  develop  the  abductor  muscles  and  the 
flexors  of  the  foot,  which  by  increased  power  will  in  a  measure 
counterbalance  the  muscles  which  have  been  so  powerful. 

The  patient  should  lie  on  the  back  on  a  hard  table,  and  should 
separate  the  legs  as  far  as  possible  at  first  without  being  touched, 
and  then  against  slight  resistance.  The  abductor  muscles  can  be 
felt  to  develop  day  by  day  under  this  training.  The  legs  in  the 
extended  position  should  be  rotated  outward,  while  the  heels  are 
kept   together.     The   foot   should   be   bent   to   a   right   angle  (and 


596  -  ORTHOPEDIC  SURGERY. 

further  if  possible)  against  resistance,  while  the  patient  lies  \\\  the 
same  position.  In  walking  the  patient  should  be  cautioned  to  go 
very  slowly,  to  lift  each  foot  well  off  of  the  ground  and  to  turn  out 
the  toes  with  much  care.  In  connection  with  massage  and  rub- 
bing, this  method  of  treatment  is  capable  of  accomplishing  a  de- 
cided change  in  the  method  of  walking,  and  while  the  walk  still  is 
stiff  and  unsteady  it  has  lost  the  characteristic  scraping  and  drag- 
ging of  the  spastic  gait.  Such  patients  walk  with  much  less  fatigue 
than  before  and  feel  much  more  steady  upon  their  feet. 

The  mental  training  of  such  children  is  a  matter  of  the  greatest 
importance  in  order  to  render  as  active  as  possible  the  remaining 
functions  of  the  brain.  One  has  only  to  visit,  an  institution  adapted 
to  the  teaching  of  such  children  to  appreciate  the  great  advantages 
that  such  special  teaching  offers  over  that  of  the  ordinary  school 
training.  The  disappearance  of  the  aphasia  is  aided  by  systematic 
training  and  it  always  proves  more  tractable  than  in  the  adult.  The 
epileptic  attacks  are  not  likely  to  be  helped  by  medicinal  treatment, 
on  account  of  the  nature  of  the  lesion  causing  them.  Attacks  of 
petit  inal  are,  however,  much  helped  by  bromides  as  a  rule. 

Operative  Treatment. 

Unlike  the  contraction  met  with  in  infantile  paralysis,  the  spasm 
in  cerebral  paralysis  immediately  returns  after  the  removal  of  the 
mechanical  correction.  This  can  be  demonstrated  readily  by  man- 
ual attempts  to  overcome  the  deformity,  and  it  has  been  found  to 
be  true  in  the  use  of  appliances  in  cases  of  this  sort.  Instrumental 
treatment  will  often  prove  unsatisfactory  for  this  reason.  The  neu- 
rologists, especially  Gowers,  have  emphatically  condemned  tenot- 
omy in  this  class  of  cases  as  useless,  irrational,  and  dangerous,  and 
have  asserted  that  it  was  likely  to  result  in  the  distortion  or  impair- 
ment of  the  muscle  divided.  The  theoretical  objections  to  tenotomy 
would  naturally  be  of  much  weight,  if  any  clear  explanation  of  the 
true  condition  of  the  muscles  could  be  given  in  these  cases.  But 
clinical  evidence  has  proved  that  tenotomy,  especially  of  the  tendo 
Achillis,  in  this  class  of  cases  is  of  much  use.  This  was  first  shown 
by  Rupprecht,  who  reported  a  number  of  cases  Avhere  the  deformity 
was  permanently  cured  by  the  division  of  the  tendo  Achillis. 

This  has  also  been  the  experience  of  Gibney,  of  New  York,  and 
the  writers  would  unhesitatingly  claim  great  benefit  for  the  opera- 
tion in  suitable  cases.  The  orthopedic  surgeon  will  meet  a  certain 
number  of  cases  of  this  class  with  pronounced  equinus  deformity 
of  one  or  both  feet.  Locomotion  is  difificult  for  the  reason  that 
it  is  impossible  for  the  patient  to  bear  the  Aveight  upon  the  whole 


CEREBRAL  I'ARALYSJS   OJ-    CHILDREN.  597 

sole  of  the  foot.  This  iiicrcruscd  (liffieulty  is  sometimes  sufficient 
to  deter  the  patient  from  efforts  of  locomotir)n  and  always  adds  to 
the  unsteadiness  of  gait,  if  tenotomy  of  tlie  tendo  Achillis  is 
done,  the  contraction  ceases,  and  though  the  strength  of  the  muscle 
is  not  lost  in  a  number  of  cases  which  have  been  watched  by  the 
writers  for  several  years,  there  is  no  tendency  to  a  reappearance  of 
the  equinus  deformity,  in  this  differing  from  what  is  not  infre- 
quently observed  in  similar  deformities  of  infantile  paralysis. 

In  a  few  instances  of  this  sort  a  practical  cure  has  been  gained 
by  tenotomy.  This  treatment  is  especially  suited  to  those  cases 
where  there  is  no  mental  disturbance  and  where  the  upper  extrem- 
ities are  not  affected,  but  it  is  not  by  any  means  confined  to  these 
cases.  The  writers  have  been  led  by  these  facts  to  attempt  the 
division  of  the  hamstring  muscles  and  adductors  in  severer  cases 
of  this  same  type,  with  improvement  of  gait  and  locomotion.  In 
one  instance  of  marked  contraction  of  both  knees  as  well  as  of  the 
tendo  Achillis,  besides  the  tenotomy  it  was  decided  to  thoroughly 
divide  the  hamstring  muscles,  and  this  was  done  by  an  open  inci- 
sion, and  all  muscular  bands  which  remained  contracted  at  the  knee 
were  thoroughly  divided  while  the  patient  was  under  an  anaesthetic. 
The  result  was  a  permanent  correction  of  the  deformity  of  the 
contracted  knee  and  an  eventual  improvement  in  gait. 

In  another  instance  the  tendo  Achillis  on  both  sides  was  tenot- 
omized,  the  hamstring  muscle  divided  by  open  incision  and  the 
adductors  also  divided  by  open  incision  and  tenotomy,  and  the  re- 
sult gained  thoroughly  justified  the  surgical  interference,  as  there 
was  marked  improvement  in  gait  and  attitude.  After  the  tenot- 
omy the  limb  and  foot  should  be  immediately  corrected  and  fixed 
in  a  corrected  position,  until  the  tendon  has  united  and  the  wound 
has  healed.  The  writers  do  not  attempt  to  offer  any  theoretical 
explanation  of  the  benefit  gained,  but  they  simply  present  the 
marked  improvement  to  be  often  obtained  by  surgical  interference, 
which  is  much  greater  than  can  be  gained  by  the  use  of  any  appli- 
ance or  by  massage  or  electricity.  After  tenotomy,  correction  ap- 
pliances should  be  used  for  a  few  months  to  steady  the  limb,  but 
ultimately  may  be  discontinued  and  permanently  discarded. 

Operations  on  the  Brain. — The  possibility  of  the  relief  of  epilepsy 
and  the  other  symptoms  of  cerebral  paralysis  by  surgical  interfer- 
ence at  the  seat  of  the  brain  lesion  has  not  been  overlooked.  The 
success  reached  by  Horsley  and  others  in  the  cure  of  epilepsy  by 
the  removal  of  tumors  from  the  motor  area  of  the  brain  has  led  to 
attempts  to  relieve  in  these  cases  the  epileptic  or  spastic  condition 
by  a  removal  of  the  lesion  in  the  cortex.  Two  cases  have  so  far 
been  attempted.     Dr.  Bradford  trephined  a  boy  four  years  old  who 


598  ORTHOPEDIC  SURGERY. 

was  idiotic  and  had  right  spastic  hemiplegia;  over  the  right  parie- 
tal region  was  a  scar  and  depression  apparently  due  to  the  use  of 
forceps  at  birth,  the  trephine  was  applied  at  that  point  and  a  but- 
ton removed,  but  the  brain  appeared  normal  at  that  place.  Dr. 
W.  N,  Bullard  then  located  the  lesion  in  the  motor  area  on  the  left 
side,  and  on  trephining,  a  porencephalic  defect  of  considerable  size 
was  found  there.  The  child  was  much  affected  by  the  operation 
and  died  the  next  day;  no  autopsy  was  allowed.'  Dr.  Morton 
operated  upon  a  case  were  there  seemed  reason  to  believe  that 
epileptic  attacks  were  the  result  of  a  focal  lesion  in  the  motor  area. 
No  focal  disease  was  found  in  the  piece  of  cortex  removed,  but  the 
spasm  in  the  arm  was  lessened  and  the  epileptic  attacks  were  re- 
duced in  frequency.     The  case  is  XCVII.  in  Osier's  series. 

With  regard  to  the  relief  of  these  conditions  by  operative  mea- 
sures the  nature  of  the  lesions  should  be  borne  in  mind  which  are, 
as  we  have  seen :  (i)  foci  of  destroyed  brain  tissue  due  to  apoplexy, 
embolism,  or  perhaps  thrombosis;  (2)  sclerosis;  (3)  porencephalus. 
In  every  case  a  defect  of  tissue;  there  is  generally  nothing  to  be 
removed ;  to  make  the  hole  in  the  brain  bigger  is  not  likely  to  help 
matters,  and  also  the  existence  of  descending  degeneration  of  the 
cord  in  cases  of  long  standing  is  another  obstacle  to  successful  re- 
lief. But  in  other  cases  a  cicatricial  contraction  might  so  draw 
upon  neighboring  parts  as  to  affect  them,  and  there  is  no  reason 
why  the  removal  of  the  diseased  area  should  not  be  in  a  measure 
as  successful  as  the  cases  of  focal  epilepsy  in  adults  where  a  similar 
cause  is  at  the  root  of  the  trouble. 

In  any  event  an  antiseptic  trephining  is  not  as  a  rule  a  very  dan- 
gerous operation.  And  in  exceptional  cases,  such  as  the  glioma 
reported  by  Osier,  surgical  interference  would  probably  have  been 
of  much  benefit.  In  general,  however,  in  the  cases  of  long  stand- 
ing, very  little  can  be  expected  of  surgical  measures,  although  an 
exploratory  trephining  might  lead  to  good  results  as  in  Morton's 
case. 

In  traumatic  cases,  however,  there  seems  reason  to  think  that 
relief  might  be  afforded  by  early  trephining  and  the  removal  of 
clots.  The  whole  question  of  the  function  of  operative  surgery  in 
these  cases  is  one,  however,  to  be  settled  by  cases  rather  than  by 
theory. 

Operations  for  Deformity. — In  hemiplegia  the  deforming  contrac- 
tion may  be  relieved  by  operation,  as  has  already  been  stated. 
Where  tenotomy  is  performed,  it  should  be  followed  by  immediate 
rectification  and  corrected  fixation,  as  is  described  in  the  Chapter 
on    Club-foot.     The    tendo    Achillis    is    the    tendon   which    needs 

MV.  N.  Bullard:    Boston  Med.  and  Surg.  Journ.,  Feb.  i6th,  1888. 


GElUiBRAj.  I'/lKAf.YSJS  OF -CI 1 11. D N EN.  599 

division  most  frcciucntly,  hut  soiiictinics  tl.ic  huinstrin^j  tendons  ;dso 
need  division.  If  the  contractions  at  the  knee  are  very  severe  or 
involve  flexion  of  the  thigh,  ojjen  incision  would  be  preferable  to 
tenotomy.  The  deformity,  as  in  infantile  jjaraiysis,  might  be  so 
severe  as  to  require  osteotomy,  but  in  such  severe  cases  little  prac- 
tical benefit  can  be  hoped  for. 

Apparatus  is  suited  to  the  treatment  of  the  milder  deformities 
only.  Talipes  equino-varus  of  a  mild  degree  may  be  temporarily 
corrected  by  a  proper  appliance,  such  as  a  Taylor  shoe.  In  general 
the  deformities  are  to  be  treated  as  in  infantile  paralysis,  but  the 
muscles  cannot  be  stretched  to  an  extent  permitting  correction  of 
the  deformity.  The  deformity  returns  immediately  on  removal  of 
the  appliance;  so  that,  apart  from  the  temporary  rectification, 
apparatus  is  of  little  advantage  in  cerebral  paralysis.  The  paral- 
ysis is  commonly  so  incomplete  that  the  muscles  furnish  sufficient 
support  to  the  affected  limb,  but  owing  to  the  increased  reflex 
excitability  and  to  imperfect  motor  impulses  the  muscles  are  in  a 
state  of  spasm  and  of  uselessness  from  the  distorted  position. 
Children  with  this  affection  are  brought  by  parents  to  the  sur- 
geon with  the  request  that  braces  be  applied  to  make  the  child 
walk  and  that  spinal  supports  be  furnished. 

Circumcision  is  frequently  advised  in  cases  of  spastic  paralysis. 
But  in  the  experience  of  the  writers  little  benefit  is  gained  in  this 
affection  by  this  procedure.  When  balanitis  and  genital  irritation 
under  the  foreskin  are  present,  as  is  shown  by  painful  mincturition 
and  frequent  erections,  circumcision  is  often  needed,  but  where  a 
congenital  cerebral  defect  is  present,  as  is  the  case  in  most  of  the 
well-marked  instances  of  spastic  paralysis,  circumcision  is  a  sense- 
less interference  so  far  as  it  is  to  be  regarded  as  a  curative  measure. 

Summary. 

The  treatment  of  hemiplegia  in  the  early  stage  is,  in  a  word,  rub- 
bing and  exercise  to  keep  the  muscles  in  good  condition,  and  mental 
training;  if  possible,  when  deformity  of  the  affected  limb  comes  on, 
it  should  be  corrected  by  apparatus  or  tenotomy.  Severe  spastic 
paralysis  may  be  helped  by  cutting  resistant  tendons  where  the 
limbs  are  deformed,  but  the  distortion  is  not  likely  to  be  improved 
by  purely  mechanical  treatment.  Rubbing  and  gymnastics  are  of 
much  benefit,  and  should  be  faithfully  tried,  while  tenotomy  is  kept 
as  a  last  resort. 


CHAPTER   XVIII. 

PSEUDO-HYPERTROPHIC   AND    OTHER    PARALYSES. 

Pseudo- Hypertrophic  Muscular  Paralysis. — Progressive  Muscular  Atrophy. — ■ 

Hereditary  Ataxia. 

There  are  certain  other  motor  disturbances  affecting  children 
which  come  under  the, notice  of  the  orthopedic  surgeon  so  fre- 
quently that  a  brief  mention  of  their  characteristics  deserves  a 
place  in  this  treatise.  They  cannot,  of  course,  be  considered  in 
detail  as  in  a  work  dealing  with  neurology,  but  simply  presented  in 
their  practical  surgical  and  therapeutic  aspect.  These  affections 
are : 

I.  Pseudo-hypertrophic  muscular  paralysis. 

II.  Progressive  muscular  atrophy. 

III.  Hereditary  locomotor  ataxia. 

I.  Pseudo-Hypertrophic  Muscular  Paralysis. 

Dejinitio7i. — Pseudo-hypertrophic  muscular  paralysis  is  an  affec- 
tion of  the  muscular  system  characterized  by  a  diminution  or  loss 
of  the  functional  energy  of  certain  muscles,  and  an  abnormal  in- 
crease in  their  size  which,  together  with  diminution  in  the  size  of 
other  muscles,  is  pathognomonic.  An  atrophy  of  muscular  elements 
takes  place  in  both  enlarged  and  in  the  smaller  muscles,  but  in  the 
former  there  is  also  a  hypertrophy  of  the  accompanying  connective 
tissue  with  an  unusual  deposit  of  fat.  The  affection  is  also  known 
as  muscular  pseudo-hypertrophy,  lipomatous  muscular  atrophy, 
diffuse  muscular  lipomatosis,  myopachynsis  lipomatosa  (Uhde). 
Paralysie  myosclerosique,  paralysie  musculaire  pseudo-hypertro- 
phique. 

Etiology. — The  etiology  of  the  affection  is  obscure  in  the  extreme. 
The  disease  develops  during  childhood  in  nearly  all  the  cases,  but 
in  exceptional  instances  its  appearance  is  delayed  until  the  age 
of  eighteen  or  twenty  years.  It  affects  males  more  commonly  than 
females  in  about  the  proportion  of  four  or  five  males  to  one  female. 
The  disease  is  more  apt  to  occur  in  family  groups  than  in  isolated 
cases,  and  the  hereditary  element  is  marked. 


PSI'lUDO-ll  Vri'lR'I'NOril IC  AND    orill'.R    I'ARALYSES.      6oi 

Sometimes  the  disease  conies  on  durinj^  convalescence  from  sfjme 
illness,  but  very  often  its  onset  is  not  to  be  explained  by  heredity 
or  constitutional  condition. 

Pathology. — The  pathological  condition  consists  in  the  over- 
growth of  the  connective  tissue  in  the  muscles  and  the  wasting  of 
the  muscular  substance  proper,  while  a  deposit  of  fat  takes  place  to 
a  greater  or  less  extent.  No  constant  or  characteristic  pathologi- 
cal condition  is  found  in  the  spinal  cord,"  although  various  changes 
have  been  described,  and  the  condition  is  at  present  regarded  as  a 


Fig,  585. 


Fig.  587.  Fig.  58S. 

Figs.  58s  to  58S. — Manner  of  Rising  from  the  Ground  in  Pseudo-Hypertrophic  Paralysis. 


primary  muscular  affection,  perhaps  a  chronic  inflammatory  pro- 
cess." 

Syviptoms. — The  first  symptoms  to  attract  attention  to  the  child's 
condition  are  muscular  feebleness  and  peculiarity  of  gait.  These 
generally  precede  any  noticeable  enlargement  of  the  muscles. 
Such   children  tire  very  easily  in  walking  and   they  have  especial 

'  Med.  Chir.  Trans.,  Ivii..  p.  247,  also  Barth:  Arch.  f.  Khde.,  xii.,  1S71,  121;  Eulen- 
burg  and  Cohnheim :  Verhandlung  der  Berl.  Med.  Gesellschaft.  1S66,  p.  191;  Lancet. 
1881,  ii.,  660;  Byrom  Bramwell;  "Diseases  of  the  Sp.  Cord,"  Edin.,  1S82;  Pekelharing: 
Virch.  Archiv,  Ixxxix.,  18S2,  p.   228. 

-  Jacoby:    Am.  Journal  Nerv.  and  INIental  Disease,  iSSS. 


6o2 


ORTHOPEDIC  SURGERY. 


difficulty  in  going  up  and  down  stairs.  They  fall  often  and  in  ris- 
ing from  the  ground  they  adopt  a  procedure  which  is  the  most 
characteristic  feature  of  the  disease.  Inasmuch  as  on  account  of 
muscular  weakness  they  cannot  straighten  the  back  or  extend  the 
knees  without  assistance,  they  rise  from  the  ground  in  the  manner 
shown  in  the  figure,  using  the  muscles  of  the  arms  to  accomplish 
what  the  leg  and  back  muscles  cannot  do. 

These  children  tend  to  walk  with  legs  apart,  and  at  times  an 
awkward  gait  and  a  tendency  to  fall  are  for  a  long  period  the  only 
symptoms  of  the  affection. 

Such  patients  learn  to  walk  late  and  depend  much  in  their  pro- 
gress upon  the  assistance  afforded  by  the  furniture,  upon  which  they 


Fig.  589. — Saddle-back  Deformity  in  Muscular  Pseudo-Hypertrophy. 


lean  heavily.  In  kneeling  on  the  hands  and  knees  at  times  there  is 
to  be  noticed  a  very  characteristic  saddle-shaped  depression  of  the 
back,  which  is  due  to  the  weakness  of  the  erector  spinae  muscles. 
This  is  not  an  early  accompaniment  of  the  disease,  but  is  a  charac- 
teristic of  the  same  late  stage  when  much  lordosis  is  present  in 
standing.  The  picture  Avas  taken  from  a  patient  of  Dr.  W.  N. 
Bullard,  and  at  this  time  was  unable  to  walk  alone  or  stand  unaided. 
The  atrophy  of  the  erector  spinae  muscles  was  very  marked  (Fig. 
589). 

In  walking  these  children  throw  the  centre  of  gravity  of  the  body 
well  over  each  leg  in  turn  as  it  supports  the  body  weight.  In  this 
way  they  save  muscular  effort.  The  result  is  a  waddle  more  or  less 
marked.  They  stand  with  marked  lordosis  of  the  lumbar  spine, 
chiefly  due  to  a  weakness  of  the  lumbar  muscles.     The  lordosis  dis- 


PSEUJ)0-/f]'/'/':h'7'h'()/'Jf/C  AND   OTIfl'-R   PAA'/ILVSES.      603 

appears  wlicn  the  patient  sits  (l(;wn  -And  a  bowing  backward  of   tlic 
whole  vertebral  column  takes  its  place. 

Mental  enfeeblenient  is  associated  with  the  disease  in  many 
cases.  The  enlargement  of  the  muscles  is  usually  most  marked  in 
the  calves  of  the  legs.  On  this  account  the  parents  generally  feel 
no  anxiety  because  the  child  walks  late  or  feebly,  inasmuch  as  the 
development  of  the  legs  seems  so  remarkably  good.  Generally 
one  calf  is  slightly  more  developed  than  the  other.  Exceptionally 
the  apparent  hypertrophy  begins  in  the  upper  extremities,  and  the 
deltoid  muscles  are  usually  the  first  to  suffer.     Even  the  muscles 


Fig.  590. — Development  of  the  Calves 
in  Pseudo-Hypertrophic  Paralysis. 


Fig.  591. — Late  Stage  of  Pseudn-Hypertrophy. 


of  the  face,  neck,  and  tongue  have  been  affected.'  In  certain  cases 
the  apparent  muscular  hypertrophy  is  slight  even  when  the  patient 
is  disabled  by  the  condition. 

The  affected  muscles  are  hard  and  resistant  to  the  touch,  but  at 
times  the  sensation  in  handling  them  is  exactly  like  that  of  a  fatty 
tumor.  Often  progressive  muscular  atrophy  of  the  upper  extremi- 
ties is  present  with  pseudo-hypertrophy  of  the  lower.  Indeed 
atrophy  of,  some  of  the  muscles  is  a  constant  symptom  of  the  dis- 
ease. 

In  time  contractions  of  the  muscles  come  on,  and  consequent  dis- 
Boston  Med.  and  Surg.  Journal,  1879,  p.  247. 


6o4  ORTHOPEDIC  SURGERY. 

tortions  of  the  joints  occur  which  are  permanent.  TaHpes  equinus 
and  flexion  of  the  knees  and  hips  are  the  common  deformities. 
Lateral  curvature  of  the  spine  may  occur,  and  at  other  times  a 
permanent  flexion  of  the  spine  occurs  from  weakness  of  the  erec- 
tor spinae  muscles,  and  the  child  sits  bowed  forward.  These  con- 
ditions are  exemplified  in  the  figure,  taken  from  a  photograph  of  a 
case  of  Gowers  (Fig.  591).  But  these  deformities  mark  only  the 
late  stage  of  the  affection. 

Neither  the  reflexes  nor  the  electrical  reactions  are  modified  in 
any  degree  until  the  muscles  have  reached  a  marked  stage  of  atro- 
phy. Then  they  are  diminished  in  proportion  to  the  muscular 
wasting  and  finally  they  are  lost.  The  reaction  of  degeneration 
is  never  present.  Very  often  the  skin  over  the  affected  limb  is 
mottled  and  subject  to  vascular  changes,  indicating  some  vaso- 
motor disturbance. 

Diagnosis. — In  well-defined  cases  the  affection  in  its  later  stages 
is  not  likely  to  be  mistaken  for  anything  else.  The  peculiar  gait 
with  the  feet  wide  apart  and  a  reckless  disregard  of  falls,  the  char- 
acteristic method  of  rising  from  the  floor,  the  age  of  the  patient, 
and  the  progressive  character  of  the  disease  all  suggest  this  affec- 
tion. If  examination  shows  enlargement  of  the  calf  muscles  and 
normal  or  diminished  reflexes  the  diagnosis  may  be  considered  as 
established.  Yet  of  even  greater  diagnostic  importance  than  the 
enlargement  of  the  calf  muscles  is  the  combination  of  enlargement 
of  the  infra-spinatus  and  wasting  of  the  latissimus  dorsi  and  pecto- 
ralis  major  muscles — a  state  of  affairs  to  which  Gowers  attaches 
the  greatest  diagnostic  importance  (Fig.  592)., 

Early  hypertrophic  paralysis,  idiocy,  spastic  paralysis,  the  paraly- 
sis of  rickets  and  Pott's  disease,  and  the  gait  from  simple  weakness 
have  very  much  in  common. 

The  differentiation  of  spastic  paralysis  from  pseudo-hypertrophic 
paralysis  has  been  considered  at  length  in  Chapter  XVII. 

Progressive  nmscular  atrophy  is  a  condition  so  closely  allied  to 
pseudo-hypertrophy  that  it  is  not  possible  to  lay  down  any  definite 
rules  for  their  differential  diagnosis.  The  best  writers,  in  fact, 
speak  of  pseudo-hypertrophy  as  a  form  of  muscular  atrophy. 

Simple  backwardness  is  often  hard  to  distinguish  from  early 
pseudo-hypertrophy,  but  it  lacks  all  the  characteristic  features  of 
the  latter,  although  sometimes  the  diagnosis  must  be  left  for  time 
to  settle. 

Prognosis. — The  prognosis  is  as  unfavorable  as  possibl-e.  Recov- 
ery is  all  but  unknown,'  and  arrest  of  the  disease  is  very  rare."" 

'  Duchenne:    Arch.  Gen.  de  Med.,  1868,  i.,  pp.  5  and  6. 

=  Donkin:    "  Note  on  a  case  of  Pseudo-Hypertrophic  Paralysis,  Recovery,"  Brit.  Med. 
Journal,  April  15th,   1882. 


PSEUDO-lIVri'-KTROI'lIIC/lND   OTJIh.R   PANALYSl-lS.      Oq: 


The  course  of  the  ch'sease  is  essentially  cliroiiic.  The  earliest 
stage,  which  is  made  manifest  by  muscular  feebleness,  lordosis,  and 
peculiar  gait,  lasts  several  months  or  a  year  and  then  passes  on  to 
a  stage  where  hypertrophy  of  the  muscles  becomes  evident,  which 
oftenest  begins  in  the  calves  and  extends  to  the  upper  extremities. 
This  stage  is  progressive  and  generally  continues  for  about  eighteen 
months,  at  the  end  of  which  time  the  pseudo-hypertrophy  reaches 
its  maximum  and  the  disease 
becomes  stationary  and  re- 
mains so  for  two  or  three  or 
perhaps  several  years.  Then 
comes  a  time  of  increasing 
feebleness  and  extension  oi 
the  paralysis.  .  The  muscles 
Avaste  and  the  power  of  move- 
ment is  lost  in  the  legs  and 
arms.  In  this  deplorable  con- 
dition the  patient  may  live  on 
until  death  comes  from  in- 
creasing exhaustion  or  some 
intercurrent  disease.  There 
is  never  sufficient  impairment 
of  the  respiratory  muscles  to 
cause  death  directly,  but  death 
most  often  comes  between  the 
ages  of  twelve  and  twenty 
years  and  is  due  to  some  pul- 
monary disease. 

At  times,  however,  the  dis- 
ease, after  remaining  for  a 
long  time  apparently  station- 
ary, passes  to  a  rapidly  fatal 
issue. 

Treatment. — Pseudo-hyper- 
trophic   paralysis  is  one   of  the    Fig.  592.— PseuJ  .-llypenrophicFaralysis,  Enlargemciuu: 
few   affections    where    there     is     Infra-Spinatus,  and  Absence  of  Lati.simusDorsi  Muscles. 

not  even  a  list  of  drugs  to  be  tried.  It  is  practically  hopeless  from 
the  time  that  the  diagnosis  is  made,  and  there  is  no  reason  to  be- 
lieve that  drugs  haVe  had  any  effect  in  retarding  its  progress.  Ar- 
senic, phosphorus,  iodide  of  potash,  and  strychnine  are  the  drugs 
which  are  used  when  medicinal  treatment  is  advisable.  Electricity 
is  sometimes  of  benefit  in  connection  with  other  treatment,  but,  as 
Gowers,  says  "  we  have  no  facts  whatever  to  justify  the  expectation 
that  any  form  of  electricity  that  could  be  applied  to  the  muscles. 


6o6  ORTHOPEDIC  SURGERY. 

would  influence  the  interstitial  growth  of  fibrous  tissue,  or  that 
any  electrical  stimulation  of  the  fibres  can  save  them  from  the 
destructive  influence  of  the  compression  they  endure." 

There  is,  however,  one  rational  mode  of  treatment  in  systematic 
muscular  exercise  and  gymnastics,  calculated,  as  in  infantile  paral- 
ysis, to  keep  the  remaining  muscular  fibres  in  the  best  possible 
state  of  nutrition  and  to  ward  off  the  permanent  contractures. 

Tenotomy  is  of  much  use  as  soon  as  the  heels  are  drawn  up. 
Often  walking  may  become  impossible,  chiefly  on  that  account,  and 
division  of  the  tendo  Achillis  on  both  sides  may  restore  for  a  long 
time  the  power  of  walking;  also  tenotomy  of  the  hamstring  ten- 
dons at  the  knee  may  be  indicated  in  severe  cases. 

By  these  means  of  muscular  exercise  and  tenotomy,  joined  with 
attention  to  the  general  condition,  much  may  be  done  to  better  the 
condition  of  these  unfortunate  patients. 

II.  Progressive  Muscular  Atrophy. 

Progressive  muscular  atrophy  is  an  affection  characterized  by  a 
wasting  of  the  voluntary  muscles,  and  a  consequent  diminution  in 
their  povv^er,  which  pursues  a  chronic  course  and  attacks  succes- 
sively individual  muscles  and  groups  of  muscles. 

It  is  spoken  of  by  some  writers  (Gowers  for  instance)  under  two 
headings,  spinal  muscular  atrophy,  where  it  evidently  proceeds  from 
a  lesion  of  the  spinal  cord,  and  idiopathic  muscular  atrophy,  where 
the  primary  change  seems  situated  in  the  muscles.  The  symptoms 
are  much  alike. 

The  idiopathic  form  of  muscular  atrophy  is  commonly  an  hered- 
itary and  often  a  congenital  affection.  The  spinal  form  is  almost 
never  seen  before  the  age  of  puberty. 

Etiology.- — In  muscular  atrophy  as  it  occurs  in  children,  the  only 
cause  assignable  is  a  congenital  tendency,  often  inherited-  But  at 
times  isolated  cases  are  met,  and  in  adults  other  causes  are  to  be 
taken  into  account.  These  are  excessive  muscular  exertion,  syph- 
ilis, exposure  to  cold  and  wet,  sexual  excesses,  injuries  of  various 
kinds,  and  at  times  the  affection  develops  during  convalescence 
from  measles,  typhoid,  rheumatism,  and  even  childbed. 

Males  are  more  often  affected  than  females,  and  the  time  of  onset 
of  the  disease  is  most  variable ;  it  may  begin  as  early  in  life  as  at 
the  age  of  three  years  or  as  late  as  sixty,  but  its  development  in 
advanced  life  is  rare. 

Pathology. — The  pathological  condition  consists  in  a  wasting 
of  the  muscles,  which  are  generally  of  a  pale  red  color  or  even  buff 
in  extreme  cases,  and  streaks   of  adipose  tissue  may  run   between 


PSEU1)0-JI  yri'lRTROJ'JUC  ANJ)   OTlIh'.h'   J'ARALYSES.      Coy 


the  fibres.     The  first  is  a  hyperplastic  growth  of  the  perimysium, 
and  wasting  of  the  muscular  tissue  goes  side  by  side  with  this  process. 

In  the  cord  there  are  sometimes  no  changes,  while  in  other  cases 
there  is  a  destruction  of  the  ganglion  cells  in  the  anterior  cornua, 
with  perhaps  degeneration  of  the  posterior  columns  and  horns. 

For  a  more  detailed  account  of  the  pathological  condition,  the 
reader  is  referred  to  the  admirable  accounts  of  Ross  (Vol.  I.,  p. 
960),  and  Gowers  (vol.  I.,  p.  368). 

Symptoms. — The  disease  is  most  insidious  in  its  onset.  In  nine- 
tenths  of  all  cases  the  wasting  begins  in  the  muscles  of  the  hands 
and  arms.  But  when  it  begins  in  children, 
it  is  apt  to  attack  the  lumbar  muscles  '  and 
later  the  muscles  of  tiie  legs.  As  in  muscu- 
lar pseudo-hypertrophy,  the  latissimus  dorsi 
and  pectoralis  major  are  often  attacked  and 
atrophied.  With  the  exception  of  the  supi- 
nator longus  the  forearm  muscles  generally 
escape.  At  times  there  is  an  affection  of 
the  face,  the  zygomatic  muscles  fail  and 
the  orbicularis  oris  muscle  is  affected.  As 
a  result  the  face  has  a  very  dull  expression 
and  the  aspect  is  so  peculiar  that  it  has 
been  termed  the  myopathic  face.  During 
the  progress  of  the  disease,  certain  muscles 
and  groups  of  muscles  are  affected,  while 
their  neighbors  are  spared.  In  children  one 
sees  sometimes  the  atrophy  of  a  group  of 
muscles  in  the  leg,  for  instance,  while  all  the 
others  remain  healthy;  it  may  appear  as  if 
the  affected  muscles  had  been  cut  out  from 
under  the  skin,  so  sharp  is  their  limitation. 
The  affection  is  not  necessarily  symmetri- 
cal.    Weakness  and  disability  of  the  affected   ^''^-  593-  Lordosis  m  idiopathic 

^  _  Muscular  Atrophy. 

muscles    is  the    only  symptom    complained 

of,  and  this  is  proportionate  to  the  amount  of  atroph}\     The  affec- 
tion is  not  characterized  by  any  marked  peculiarity  of  gait. 

The  electrical  changes  are  slight.  The  reflexes  and  faradic  irri- 
tability diminish  as  the  muscles  waste,  and  in  the  later  stages  of 
the  affection  slight  qualitative  changes  are  manifest  in  the  gal- 
vanic reaction.  Fibrillary  tAvitchings  in  the  muscles  are  very  com- 
mon at  all  stages  of  the  disease.  Sensation  is  generalh-  unimpaired, 
but  vaso-motor  disturbances  and  trophic  changes  of  the  skin  over 
the  affected  muscles  ma}'  be  present. 

^  Friedreich:    "  Ueber  Prog.  Muskelatrophie,"  1S73,  p    20S. 


6o8  ORTHOPEDIC  SURGERY. 

Contractions  and  deformities  may  come  on  in  consequence  of 
the  unopposed  action  of  healthy  muscles,  such  as  talipes  equinus, 
lordosis,  and  lateral  curvature. 

Diagnosis. — -The  principal  diagnostic  feature  of  muscular  atrophy 
is  found  in  the  marked  and  progressive  wasting  of  muscular  tissue, 
which  is  at  times  strictly  local.  The  reflexes  are  not  affected  ex- 
cept through  the  loss  of  muscular  power,  and  the  disability  results 
only  from  the  impaired  muscular  force.  Electrical  reactions  are 
normal  until  a  late  stage  of  the  disease. 

The  condition  most  likely  to  be  mistaken  for  progressive  mus- 
cular atrophy  is  paralysis  and  wasting  due  to  the  mechanical  injury 
of  some  nerve.  Here  the  wasting  is  sharply  localized  in  both 
cases,  but  the  history  of  an  injury  would  be  present  in  cases  of 
nerve  lesion,  the  paralysis  would  have  come  on  suddenly  and  re- 
mained sharply  limited  to  the  distribution  of  that  one  nerve,  and  in 
the  case  of  injury  to  a  mixed  nerve  sensation  would  have  been 
impaired.  The  paralysis  would  of  course  have  preceded  the 
wasting. 

A  typical  case  of  infantile  paralysis  at  times  resembles  somewhat 
progressive  muscular  atrophy.  It  can  be  said  that  infantile  paral- 
ysis comes  on  suddenly,  the  paralysis  precedes  the  wasting  and  is 
most  marked  when  it  is  first  noted,  the  reflexes  are  lost,  and  the 
"  reaction  of  degeneration  "  is  present. 

Prognosis. — The  disease  is,  as  a  rule,  steadily  progressive  and  it 
follows  no  definite  course  in  the  matter  of  time.  In  one  case  it 
may  be  thirty  or  forty  years  in  reaching  its  height,  in  another  case 
beginning  at  the  same  age  it  may  develop  to  complete  paralysis  in 
eight  years. 

In  general  the  prognosis  is  not  favorable.  An  arrest  of  the  dis- 
ease, however,  may  be  hoped  for  and  if  it  occurs  it  may  be  perma- 
nent. This  is  most  likely  to  happen  in  the  partial  cases  where  the 
disease  afTects  only  one  extremity  and  does  not  show  a  tendency  to 
become  generalized.  Where  it  begins  to  affect  the  trunk  muscles 
it  always  ends  fatally,  generally  by  impairment  of  respiration  and, 
for  this  reason,  cases  which  begin  in  the  shoulder  are  particularly 
grave.  The  hereditary  form  of  the  disease,  as  it  occurs  in  children, 
is  particularly  liable  to  become  generalized,  and  the  prognosis  is 
therefore  bad. 

Any  tendency  to  generalization  or  rapid  increase  of  the  paralysis 
is  extremely  unfavorable,  and  in  cases  which  have  shown  a  tendency 
to  increase  rapidly  no  hope  should  be  given.  The  prognosis  is 
best  when  the  affection  is  caused  by  overwork  and  is  confined  to 
the  hands  and  arms. 

Treatment. — Drugs  are  practically  useless  in  this  affection.     The 


PSKUDO-JnTI'lRTROrilJC  AND    OT/f /■:/,'    I'/i A'/l /.VSKS.      609 

only  one  advocated  is  stryclmine  ^iven  suhcutaneously,  from  which 
Gowers  tliinks  lie  has  seen  at  times  decided  imj^rovement.  It  is 
best  used  in  the  form  of  the  nitrate  in  doses  of  „'„  to  4^,,  of  a  yrain, 
given  once  a  day  only.  In  cases  where  syphilis  has  preceded  the 
affection,  antisyphilitic  treatment  should  be  tried,  but  it  is  rarely 
of  any  benefit. 

It  is  of  the  greatest  importance  to  attend  most  carefully  to  the 
patient's  hygiene  and  surroundings,  in  order  so  as  far  as  possible 
to  render  the  system  resistant  to  the  disease.  The  greatest  hope 
must  be  placed  in  local  treatment  to  the  affected  muscles.  Elec- 
tricity sometimes  seems  to  be  of  distinct  benefit,  and  is  almost 
always  used;  more  commonly,  however,  it  is  only  too  plain  that  it 
is  of  no  practical  use  in  arresting  the  disease.  It  is  probably  of 
some  service  inasmuch  as  it  tends  to  keep  up  the  muscular  nutri- 
tion. "  If  the  malady  is  progressing  at  the  same  rate  in  each  arm, 
and  the  muscles  of  one  arm  are  regularly  treated  by  electricity,  and 
those  in  the  other  arm  are  let  alone,  no  difference  can  be  detected 
in  the  rate  of  wasting  on  the  two  sides." '  Either  current  may  be 
used,  giving  the  preference  to  the  one  that  stimulates  the  muscles 
the  most  easily,  and  the  use  of  strong  currents  should  be  carefully 
avoided. 

Rubbing  and  massage  not  only  delay  or  prevent  the  occurrence 
of  deformity,  but  they  keep  the  muscles  in  the  best  possible  condi- 
tion, and  at  times  seem  to  delay  the  progress  of  the  affection. 
They  should  be  begun  at  the  earliest  possible  moment  and  faith- 
fully followed  out. 

III.  Hereditary  Ataxia. 

Hereditary  ataxia  deserves  mention  as  a  serious  motor  disorder 
which  is  sometimes  met  in  children.  It  is  dependent  upon  a  family 
predisposition,  but  is  not  often  directly  inherited,  but  more  com- 
monly appears  in  several  members  of  one  generation.  Hence  the 
name  of  family  ataxia.  It  is  also  known  as  Friedreich's  disease, 
in  honor  of  the  man  who  first  described  the  condition.  Other 
names  are,  hereditary  ataxic  paraplegia,  and  degenerative  ataxia. 

The  cases  are  rare  in  the  extreme,  and  only  120  have  been  so  far 
reported  in  the  journals."  Dr.  Everett  Smith  collected  all  cases 
reported  up  to  1885,  which  were  only  57  in  number.^ 

Etiology. — Aside  from  the  influence  of  a  congenital  tendency  the 
cause  of  the  disease  is  as  yet  unknown.  The  disease  develops  most 
often  at  about  the  age  of  seven  or  eight  years,  in  another  group 

'  Gowers:    Vol.  i. ,  p.   3S0. 

^  Shattuck:    Bost.  Med.  and  Surg.  Journal,  vol.  cxviii. ,  7,  p.  168. 

3  Smith:    B.  M.  and  S.  Journal,  Oct.  isth,  18S5. 

39 


6lO  ORTHOPEDIC  SURGERY. 

of  cases  it  develops  at  puberty,  and  in  other  cases  still  it  is  made 
evident  any  time  between  the  fourth  and  the  twenty-fifth  year.  The 
sexes  seem  equally  liable  to  the  affection. 

Pathology. — In  examining  sections  of  the  cord  in  these  cases,  a 
degeneration  of  the  lateral  columns,  with  a  more  intense  and  plainly 
marked  sclerosis  of  the  posterior  columns,  is  found.  This  is  similar 
to  the  lesion  of  locomotor  ataxia. 

SyjHptoms. — The  symptoms  resemble  very  closely  those  of  loco- 
motor ataxia,  except  that  the  lightning  pains  of  the  early  stage  are 
absent  and  crises  are  not  marked  as  in  the  latter  affection.  Hered- 
itary ataxia  moreover  involves  the  upper  extremities  more  severely 
and  earlier  in  the  course  of  the  affection. 

The  earliest  symptoms  of  the  affection  are  slight  and  consist 
often  of  dyspnoea  and  irritable  heart  and  stomach;  but  of  course 
these  symptoms  rarely  come  under  the  physician's  observation. 
Then  the  patient  notices  a  feeling  of  weakness  and  uncertainty  in 
walking  and  soon  it  becomes  apparent  to  others  that  the  motions 
of  the  legs  are  not  properly  coordinated.  The  feet  are  placed  wide 
apart  in  standing,  and  in  walking  the  gait  is  practically  that  of 
locomotor  ataxia.  The  movements  of  the  hands  become  irregular 
and  incoordinate  and  a  jerky  irregularity  develops  in  the  movements 
of  the  head  and  neck,  so  much  so  that  it  may  assume  the  aspect  of 
an  irregular  tremor.     Speech  may  also  be  impaired. 

The  knee-jerk  disappears,  but  the  plantar  reflex  remains,  curi- 
ously enough.  .  Sensation  is  affected  in  varying  degrees  in  differ- 
ent cases,  and  trophic  disturbances  of  the  skin  are  not  present. 
As  a  rule  the  sphincter  muscles  are  not  affected. 

Deformities  are  apt  to  come  on  in  the  later  stages  of  the  disease. 
In  two  cases  recently  seen  by  the  writers,  marked  rotary  lateral 
curvature  was  present  and  talipes  equinus  and  permanent  flexion 
of  the  knee  are  likely  to  occur. 

Diagnosis. —  In  a  clearly  marked  case,  the  walk  is  characteristic 
and  exactly  like  that  of  ordinary  locomotor  ataxia.  The  reflexes 
are  diminished  or  absent  and  there  is  a  certain  amount  of  disturb- 
ance of  sensation;  the  electrical  reactions  are  normal.  Isolated 
cases  occur  but  rarely,  and  one  finds  most  often  a  history  of  some 
such  affection  in  other  members  of  the  same  family,  which  of  course 
aids  very  much  in  the  diagnosis. 

Progjiosis. — The  disease  is  essentially  progressive,  and  the  prog- 
nosis is  bad  in  proportion  to  the  rapidity  of  progress.  Death  usu- 
ally occurs  from  intercurrent  affections,  but  sometimes  the  disease 
lasts  for  thirty  years  or  more  and  does  not  seem  to  have  shortened 
life.  It  is  not  likely  to  cause  death  inside  of  ten  or  twelve  years 
at  the  least,  and  nothing  must  be  expected  from  treatment. 


rSEUDU-ll  \-l'l':R'rR()l'I//C  AND    ()'nil-:i<    rAKALYSICS.      6ii 

Treatment. — The  treatment  sliould  be  similar  to  t]i,-i.t  in  common 
use  in  locomotor  ataxia  of  the  re^ailar  tyi)e,  but  the  outlook  is 
not  so  good,  for  the  congenital  tendency  adds  much  to  the  gravity 
of  the  outlook. 

The  general  hygiene  of  the  patient  should  be  most  carefully  reg- 
ulated and  skilful  massage  sometimes  accomjjlishes  wonders  in 
keeping  up  the  nutrition  of  the  muscles  and  thus  diminishing  tlie 
patient's  disability.  In  this  affection,  where  the  nutrition  of  the 
muscles  is  of  the  greatest  importance,  the  manipulation  of  a  skilled 
masseur  is  especially  to  be  preferred  to  the  rubbing  of  an  amateur. 
Electricity  in  the  same  way  is  of  use,  but  it  is  distinctly  second  in 
importance  to  proper  massage. 


CHAPTER  XIX. 

RICKETS. 

Definition. — Pathological  Anatomy. — Occurrence  and  Etiology. — Symptoms, 
Diagnosis. — Differential  Diagnosis. — Prognosis. — Treatment. 

Rickets  is  a  constitutional  disease,  caused  by  malnutrition,  which 
affects  young  children.  Its  chief  characteristics  are  manifested  in 
the  osseous  system,  where  there  is  a  local  or  general  disturbance  of 
the  normal  profcess  of  ossification,  as  a  result  of  which  the  epiphy- 
ses become  enlarged  and  the  affected  bones  become  soft  and  plia- 
ble ;  growth  is  delayed  and  deformities  of  a  very  serious  character 
arise. 

The  affection  itself  does  not  belong  to  the  category  of  surgical 
diseases;  but  the  resulting  "  deformities,"  which  demand  strictly 
surgical  treatment,  are  connected  with  the  disease  itself  so  inti- 
m.ately  that  a  brief  consideration  of  the  subject  is  necessary.  The 
affection  itself  is  so  fully  discussed  in  books  relating  to  the  dis- 
eases of  children  that  the  reader  can  be  referred  to  them  for  any 
detailed  account  of  the  disease. 

The  disease  is  known  in  English  by  two  separate  names,  rickets 
or  rhachitis.  The  former  is  the  older  English  name  and  is  derived 
either  from  the  Saxon  word  "  rick,"  a  hump,  or  from  a  Dorsetshire 
verb  "  rucket,"  to  breathe  laboriously.  Inasmuch  as  the  disease  in 
England  first  appeared  in  Dorset  (according  to  Glisson),  and  as 
the  first  description  of  the  affection  was  given  by  English  writers 
two  centuries  and  a  half  ago,  there  seems  no  reason  to  discard  the 
original  name  rickets,  which  will  be  retained  here.  The  word 
"rachitis"  was  invented  by  Glisson,  of  Cambridge,  in  the  17th 
century,  who  derived  this  from  the  Greek  paxi-i,  the  spine,  on  the 
ground  that  the  spine  was  the  region  first  affected.  If  this  was 
the  derivation,  however,  the  English  word  should  have  been  spelled 
rhachitis,  and  this  more  correct  orthography  has  been  recently 
adopted  by  continental  writers,  among  whom  the  more  classical 
term  invented  by  Glisson  has  always  met  with  better  acceptance 
than  the  original  English  name  of  rickets.  The  spelling  rhachitis 
instead  of  the  more  common  way,  rachitis,  has  been  adopted  here 


RicKirrs.  613 

as  the  one  unquestionably  correct,  in  view  of  tlie  Greek  derivation. 
The  cHsease  is  also  known  by  the  f(jllowiny  names: 

Morbus  Ani^licus,  articuli  duplicati. 

German:   Enf^lische  Krankheit,  Zwiewuchs,  doppelte  Glieder. 

P'rench :   Rachitisme,  nouure. 

Italian:   Rachitide. 

Pathological  Anatomy. 

The  most  obvious  characteristic  feature  of  the  disease  is  a  de- 
fective calcification  of  the  bones,  in  consequence  of  which  second- 
ary changes  occur  in  rapid  succession. 

The  pathological  changes  of  the  active  stage  are  most  marked  at 
the  junction  of  the  epiphysis  and  the  shaft  of  the  long  bones.  The 
cartilage  between  the  two,  which  should  normally  be  a  tliin  layer 
only  one  or  two  millimetres  thick,  in  rickets  appears  as  a  broad 
reddish-gray  translucent  cushion,  while  the  whole  epiphysis  is  en- 
larged and  softened. 

Normal  ossification  is  of  course  impossible  under  these  circum- 
stances, and  the  growth  of  the  bone  is  delayed. 

Beneath  the  periosteum  of  the  bones  acondition  similar  to  that 
in  the  epiphyses  is  found ;  the  soft  and  vascular  layer  which  lies 
under  the  periosteum,  which  is  thin  and  scarcely  noticeable  in  the 
normal  state,  when  rickets  is  present  becomes  thick  and  appears 
dark,  like  spleen  pulp.  The  periosteum  itself  is  thickened  and 
boggy,  and  is  detached  from  the  bone  with  great  difificulty,  often 
tearing  off  spicules  of  bone  with  it. 

The  periosteum,  bone,  and  epiphyses  are  all  infiltrated  w^ith  a 
fluid  which  Trousseau  speaks  of  as  much  like  "  red,  pale  goose- 
berry jam."  The  medullary  cavity  increases  in  size,  contributing 
to  the  weakness  of  the  bone.  The  bones  of  the  skull,  the  ribs, 
and  the  wrists,  are  most  often  affected. 

The  proportion  of  organic  to  inorganic  matter  in  the  bones  is 
very  much  increased. 

Bodily  weight  and  muscular  action  are  always  at  work  to  twist 
and  curve  the  softened  bones,  and  there  seems  scarcely  a  limit  to 
the  harm  that  might  result  if  a  reparative  change  did  not  set  in. 
This  happens  when  the  deposit  of  lime  begins  again,  as  it  almost 
always  does,  in  the  proliferating  layers.  From  being  most  scanty, 
lime  deposition  or  ossification  becomes  excessive  and  the  bone  is 
laid  down  with  such  rapidity  and  so  densely  that  the  process  is 
spoken  of  as  petrifaction  or  eburnation,  rather  than  true  ossifica- 
tion. 

The  ligaments  become   relaxed  and  stretched   and  the  muscles 


6 14  ORTHOPEDIC  SURGERY. 

flabby  and  shrunken,  chiefly  from  disuse.  The  spleen  is  ordinarily 
enlarged  and  sometimes  the  liver  and  lymphatic  glands.  Some- 
times, however,  fatty  infiltration  of  the  liver  is  present.'  Patho- 
logical changes  due  to  inflammation  and  catarrh  of  the  alimentary 
canal  are  very  common ;  and  in  the  trachea  one  finds  the  appear- 
ances of  a  bronchitis  of  greater  or  less  severity. 

The  brain,  as  a  rule,  is  found  after  death  well  developed.'  If 
rickets  of  the  skull  is  present  to  any  extent,  one  finds  that  the 
membranes  and  brain  itself  have  participated  somewhat  in  the  pro- 
cess, for,  in  addition  to  the  succulency  and  redness  of  the  bones  of 
the  skull,  the  brain  is  abnormally  vascular,  and  in  cases  where  this 
is  excessive  there  may  be  an  effusion  into  the  cerebrum,  the  arach- 
noid, or  the  ventricles. 

The  other  pathological  appearances  are  more  properly  to  be 
considered  under  the  head  of  symptoms. 


Occurrence  and  Etiology. 

Rickets  occurs  chiefly  at  three  periods  of  life :  as  a  congenital 
affection,  early  in  childhood,  and  in  adolescence.  The  occurrence 
of  congenital  rickets  is  perfectly  well  established  by  numerous 
observations. 

Such  cases  of  congenital  rickets  have  been  reported  by  Jacobi,^ 
Gueniot,''  Henoch,^  Shattock,*^  Lewis  Smith  ^  (with  skeleton),  Hink 
and  Winkler,  Bednar,**  and  others,  and  Virchow  lends  his  authority 
to  its  not  uncommon  occurrence.  Kassowitz,  in  a  series  of  dissec- 
tions of  still-born  infants  and  children  dying  very  young,  in  the 
Vienna  Foundling  Hospital,  found  a  rhachitic  change  in  the  ends 
of  the  bones  in  a  large  number. 

The  common  time  of  occurrence  is  early  in  childhood;  cases  are 
reported  where  the  "  rhachitic  rosary "  was  seen  as  early  as  the 
fourth'  and  sixth '°  weeks  after  birth.  The  following  collection  of 
1876  cases  will  show  the  tendency  of  the  disease  to  occur  in  the 
first  two  years  of  life. 


'  Brit.  Med.  Journ.,  Nov.  24th,  1888,  p.  1,150. 

°  Beneke:    "  Die  anat.  Grundlage  der  Constit.  Anomalie  des  Menschen,"  \i 

3  Jacobi:    Am.  J.  Obst.,  Nov.,  1870. 

^  Gueniot:    Rev.  Mens,  des  Mai.  de  I'Enfance,  Jan.,  1884. 

5  Henoch:    "  Dis.  of  Children." 

^  Smith:    "  Diseases  of  Children." 

7  Quoted  by  Lewis  Smith. 

^  Shattock  :    Lond.  Path.  Soc.  Trans.  1881. 

9  Parry:    Am.  J.  Med.  Sci. ,  Jan.,  1872. 

™  Gee:    St.  Earth.  Rep.,  vol.  iv. 


h'/CklCTS.  615 

1st  yr.  •.■<!  yr.  3(1  yr.  4th  yr.  5th  yr.  over  5 

Guerin 98  176  35  19  10                   5 

I'jruenische 20  79  47                 7  0                   4 

Kittershain 266  154  62  15  7                  i? 

Ritsche 72  109  *     25                 9  4  — 

Baginskey     256  313  63  —  —  — 

710  831  232  50  27  26-h 

Rickets  seldom  begins  before  six  months  or  after  three  years. 

The  rickets  of  adolescence  or  late  rickets  is  an  affection  which 
affects  persons  at  about  the  age  of  puberty ; '  it  is  generally  associ- 
ated with  albuminuria,  and  its  etiological  relations  are  decidedly 
obscure.  The  physical  signs  are  practically  the  same  as  in  the 
rickets  of  early  life,  except  that  the  epiphyseal  enlargement  is  gen- 
erally not  so  great,  Drewett  reported  a  case  to  the  London  Path- 
ological Society  in  1880  where  a  dissection  of  the  skeleton  showed 
the  same  characters  as  in  early  rickets.^  The  figure  shows  a  case 
twelve  years  old,  reported  by  Glutton,  where  the  disease  had  ex- 
isted less  than  two  years.     He  also  reports  one  other  case.' 

The  term  senile  rickets  is  applied  by  Reeves  to  a  similar  bone 
softening  which  occurs  in  adult  life  and  especially  in  elderly  per- 
sons. The  phanges  present  a  close  resemblance  to  those  of  true 
rickets.  A  similar,  or  the  same,  affection  is  spoken  of  as  mollities 
ossium. 

Such  cases  of  local  or  general  bone  softening  in  adult  life  are 
rarely  met  with  outside  of  certain  districts  bordering  on  the  Rhine, 
although  occasionally  one  sees  them  in  England  and  America. 
Mr.  Durham'*  collected  145  cases.  The  only  etiological  factor 
which  is  definitely  known  is  the  association  of  the  disease  with 
childbirth.  In  91  of  Durham's  cases  it  began  during  pregnancy  or 
after  childbirth,  while  for  the  rest,  no  definite  cause  can  be  assigned. 

The  pathological  condition  of  the  bones  in  these  cases  is  obscure. 
The  bones  are  fragile  and  softened,  and  the  proportion  of  inorganic 
constituents  (as  in  early  rickets)  is  much  diminished. 

Other  cases  of  what  would  seem  to  be  localized  rickets  in  adults 
are  reported.  They  occur  for  the  most  part  in  young  males,  and 
the  bones  of  the  lower  leg  are  the  ones  affected.  In  the  cases  re- 
ported, a  sharp  curvature  begins  in  the  leg,  which  increases  some- 
times until  the  leg  is  bent  to  a  right  angle.  Then  repair  sets  in 
and  solidification.  This  affection  has  no  definite  etiology  or  path- 
ology.    Glisson,=  Portal,*  Oilier,^  and  Tripier-  report  such  cases. 

'  Lucas:    Lancet,  June  gth,  18S3.  -  Moxon  :    Guy's  Hosp.  Rep.,  1S7S. 

3  H.  H.  Glutton:    St.  Thos.  Hosp.  Rep.,  vol.  xiv. 

4  Durham  :    Guy's  Hosp.  Rep.,  1864.  s  Quoted  in  Ziemssen,  Art.  '"  Rachitis." 
^  Portal  :   "  Obs.  sur  la  Nature  et  Trait,  du  Rachitisrae, "  Paris,  1797. 

7  Tripier  :    "  Diet,  des  Sci.  Med.,"  iii.,  Serie  i.,  1874,   652. 


6i6 


ORTHOPEDIC  SURGERY. 


Ostitis  deformans  is  a  process  which  produces  results  similar  in 
part  to  those  of  rickets  so  far  as  regards  curvature  of  the  long 
bones.  The  condition  was  originally  described  by  Sir  James  Paget 
and  of  late  has  attracted  much  notice  in  England.'  "  The  disease 
affects  most  frequently  the  long  bones  of  the  lower  extremities  and 
the  skull  and  is  usually  symmetrical.  The  bones  enlarge  and  soften, 
and  those  bearing  weight  yield  and  become  unnaturally  curved 
and  misshapen."''  The  pathological  process  seems  to  be  a  chronic 
inflammation  of  the  bone,  with  absorption  and  attempted  repair  by 


Fig.  595. 
Figs.  594,  595. — Rickets  of  Adolescence.    (Glutton.) 


Fig.  596. — Case  of  Ostitis 
Deformans. 


the  deposition  of  new  material  as  an  ill-formed  new  bone  which  is 
soft  and  non-resistant. 

It  is  associated  in  most  cases  with  a  gouty  history  and  seems  to 
have  no  dependence  on  syphilis.  At  times  the  disease  seems  to 
have  its  origin  in  some  injury  to  a  bone.  Curvature  and  stiffness 
of  the  spine  result,  and  a  great  enlargement  of  the  skull  is  charac- 
teristic. The  process  may  be  limited  to  one  bone  or  it  may  affect 
several.  In  the  legs  it  may  be  the  cause  of  very  marked  bow  legs. 
It  tends  to  eventuate  in  malignant  disease  in    a  certain    propor- 


^  Paget:    Med.  Chir.  Trans.,  vols.  Iv.  and  Ix. 

^  Illustrated  Med.  News,  London,  Feb.  23d,  1889. 


tion  of  the  cases,  as  observed  by  Sir  James  Paj^ct.  In  eij^ht  cases 
traced  to  tlicir  death,  five  died  of  cancer  or  sarcoma,  liut  the 
affection  runs  an  extremely  chronic  course  and  shows  little  or  no 
tendency  to  shorten  life.     Treatment  is  (;f  no  avail. 

In  the  rickets  of  childhood  the  matter  of  sex  is  of  no  importance. 
In  2,595  cases  reported  from  various  authors,  there  were  i;337  boys 
to  1,258  girls. 

Heredity. — Although  certain  writers'  would  advocate  a  direct 
transmission  of  rickets  from  parent  to  child,  the  weight  of  author- 
ity seems  to  favor  the  view  that  an  inherited  weakness  of  constitu- 
tion is  inherited  rather  than  the  disease  as  such." 

As  might  be  expected,  the  younger  children  of  a  large  family  are 
much  more  liable  to  rickets  than  their  older  brothers  and  sisters. 

Inasmuch  as  rickets  is  a  disease  of  malnutrition,  the  commonest 
causes  are  to  be  sought  in  the  immediate  surroundings  of  the 
patient.  Broca's  definition  of  it  best  expresses  the  situation  when 
he  speaks  of  it  as  representing,  "  the  ultimate  effects  of  everything 
which  interferes  with  the  nutritive  processes  during  the  rapid 
growth  of  infancy." 

Locality. — -In  northern  and  middle  Europe  the  disease  is  espe- 
cially prevalent,  particularly  in  the  cities.  In  America  it  is  com- 
paratively infrequent,  and  even  in  the  European  cities  it  varies 
very  much,  if  one  can  judge  from  the  reported  figures.  The  fol- 
lowing percentages  of  all  children  attending  the  policlinics  are 
found  to  be  rhachitic  in  the  various  cities. 

Dresden,         25  per  cent,  Kuettner. 

Prague,            31         "  Ritter  von  Rittershain. 

Copenhagen,    6         "  Brueniche. 

Berlin,              11         "  from  University  Policlinic, 

Boston,              5         "  Haven. 

In  America  the  disease  is  neither  very  prevalent  nor  very  severe, 
and,  except  in  colored  children  or  in  Italians  and  Portuguese,  \-ery 
great  deformity  is  rare.  The  great  bulk  of  cases  seen  in  the  north- 
ern cities  of  America  present  essentially  a  mild  type  of  rickets 
compared  to  what  is  seen  in  Europe. 

A  number  of  children  were  taken  at  random  in  one  of  the  poor- 
est quarters  of  Boston,  and  carefully  examined  for  rickets,  and  the 
results  have  a  bearing  on  the  question  of  etiology.  The  district 
was  one  inhabited  by  Italians,  Irish,  and  Portuguese,  and  repre- 
sented the  lowest  class  of  the  population.  100  children  between 
the  ages  of   i   and  6  were  stripped  and  examined  ;    60  showed  no 

'  Parker,  Vogel  and  von  Rittershain:  "  Die  Path,  und  Ther.  der  Rachitis,"  Berlin,  1S63. 
^  Jenner  :    Med.  Times  and  Gazette,  1S60,  i.,  460. 


6i8  ORTHOPEDIC  SURGERY. 

signs  of  rickets,  and  40  were  more  or  less  rhachitic.     The  following 
figures  represent  the  very  decided  effect  of  nationality. 


Parentage. 

Total. 

Rhachitic. 

Not  Rhachitic. 

Portuguese, 

24 

20 

4 

Irish,  , 

51 

7 

44 

Italian, 

5 

3 

2 

American, 

2 

0 

2 

English, 

8 

5 

3 

Of  75  cases  of  rickets  applying  at  the  West  End  Dispensary,  as 
reported  by  Haven,  only  four  were  of  American  parentage,  and  38 
were  negroes.  The  prevalence  of  rickets  among  the  colored  popu- 
lation in  northern  cities  is  most  striking,  and  the  disease  is  not  by 
any  means  so  common  in  the  negro  population  of  the  southern 
cities.  The  great  susceptibility  to  rickets  which  is  shown  by  the 
inhabitants  of  southern  Europe  has  never  been  accounted  for. 
Not  only  is  this  to  be  noted  in  America,  but  in  Italy  the  disease  is 
so  prevalent  that  it  is  reported  by  Professor  Pini,  that  in  Milan  13 
per  cent  of  all  the  children  in  the  poorer  quarter  of  the  city  are 
rhachitic'  Fischl  finds  a  seasonal  variation  in  the  occurrence  of 
rickets  in  the  cases  at  Munich;  the  severest  cases  occurring  in  the 
winter. 

As  one  sees  the  cases  here  in  America,  they  come  from  the  low- 
est classes  of  the  population,  as  a  rule;  they  have  been  for  the 
most  part  bottle-fed  in  a  careless  way,  and  then  put  upon  general 
diet  at  a  very  early  age,  and  at  two  years  eat  the  same  food  as  the 
rest  of  the  family. ""  But  cases  of  mild  rickets  are  not  uncommon 
in  the  Northern  States,  appearing  at  times  even  in  the  better 
classes. 

Bad  hygienic  influences,  such  as  poor  ventilation,  damp  dwellings, 
crowded  rooms,  etc.,  have  a  very  marked  sway  in  producing  rickets, 
and  this  factor  is  one  which  continental  writers  make  very  promi- 
nent. 

But  in  America,  where  the  conditions  of  life  among  the  poor  are 
very  different,  rickets  is  almost  exclusively  produced  by  improper 
feeding,  and  in  England  more  attention  is  continually  being  paid 
to  this  etiological  factor.  Cheadle,^  in  a  recent  paper,  represents 
an  extreme  point  of  view  in  stating  that  he  had  seen  only  one  case 
of  rickets  which  arose  in  a  child  suckled  by  a  healthy  mother,  and 
in  this  case  the  mother  became  pregnant  during  lactation. 

Baxter'*  found  that  92  per  cent  of  the  rhachitic  children  coming 

'  Deutsche  Med.  Zeitung,  Nov,  5th,  1881. 
^  London  Med.  Times  and  Gaz.,  1881,  i.,  323. 

3  Brit.  Med.  Journal,  Nov.  24th,  1888,  p.  1,145. 

4  Trans.  Lond.  Path.  Soc,  1881,  p.  361. 


RICKETS.  619 

under  his  observation  had  been  fed  on  farinaceous  food  of  some 
kind  or  other  before  reaching  the  age  of  twelve  months,  42  per 
cent  of  whom  had  it  daily  from  the  time  of  their  birth.  Of  the  8 
per  cent  of  the  cases  who  had  not  been  given  starchy  food  before 
they  were  a  year  old,  several  were  to  be  ascribed  to  maternal 
feebleness,  one  to  syphilis,  others  to  living  underground,  etc.;  and 
in  only  one  case  was  no  cause  to  be  assigned. 

The  various  patent  foods  come  in  for  their  share  of  the  blame 
when  they  have  been  used  to  the  exclusion  of  everything  else.  The 
occurrence  of  rickets  in  an  American  baby  who  had  been  breast 
fed  would  be  a  very  unusual  thing.  Among  Italians,  Portuguese, 
and  Negroes  it  is  a  common  occurrence  under  these  conditions. 
But  where  nursing  has  been  continued  so  long  that  the  mother's 
milk  has  become  insuf^cient  and  poor  in  salts,  rickets  may  occur. 
In  general  it  is  not  so  much  the  particular  kind  of  food  which  pro- 
duces the  rickets  as  the  fact  that  it  is  unsuited  to  the  child's  age 
and  condition. 

The  experimental  production  of  rickets  has  always  played  an 
important  role  in  determining  its  etiology.  Guerin  produced  the 
disease  in  young  puppies  by  putting  them  on  a  meat  diet.  Chossat 
produced  it  in  pigeons  and  Milne  Edwards  in  young  dogs  by  a  diet 
poor  in  lime  and  phosphorus.  Friedleben,  however,  denied  that 
true  rickets  was  produced."  Heitzmann,-  finding  free  lactic  acid  in 
the  urine  of  persons  with  rickets,^  administered  lactic  acid  to  young 
animals  and  produced  typical  rickets,  but  he  restricted  the  use  of 
calcareous  food;  but  Koraskow  failed  to  produce  rickets  by  the  ad- 
ministration of  lactic  acid  along  with  proper  food.  He  obtained  it 
by  minute  doses  of  strontium  or  phosphorus  when  the  food  was 
unsuitable. 

In  menageries,  where  animals  live  under  highly  artificial  condi- 
tions, rickets  attacks  young  lions  especially,  and  is  the  cause  of 
death  in  a  large  number  of  cases.  Ostriches,  pheasants,  and-poultry 
under  the  same  conditions  have  a  softness  of  the  bones.  The 
opinion  is  now  held  at  the  London  Zoological  Gardens  that  the 
production  of  rickets  among  the  animals  there  is  caused  chiefly  by 
a  deficiency  in  the  food  of  animal  fats  and  earthy  salts. 

These  experiments  have  given  rise  to  several  theories  as  to  the 
causation  of  rickets.  Among  the  earliest,  one  may  mention  the 
lactic-acid  theory.  This  is,  that  lactic  acid  is  generated  in  excess 
in  the  intestinal  canal  by  the  fermentation  of  starchy  food  imper- 
fectly digested ;  this,  uniting  with  the  Hm.e  of  the  bones,  removes 

*  Jahrbuch  f.  Khde.,  iii.,  1S60,  p.  61. 
^  Wiener  Med.  Presse,  1S73,  14. 
•  3  "  Lehrbuch  der  Physiol.  Chem.,"  1867. 


620  ORTHOPEDIC  SURGERY. 

the  lime  as  a  soluble  salt  and  acts  also  as  an  irritant  to  the  osteo- 
plastic tissue. 

Another  theory  refers  the  cause  to  the  deficiency  in  the  food  of 
earthy  salts,  but  the  experiments  of  Friedleben  show  that  this 
alone  is  not-  enough.  A  third  theory  lays  the  fault  upon  insuf- 
ficiency of  fat  and  proteids  in  the  diet  of  rhachitic  children.  Arti- 
ficial farinaceous  foods  contain  a  very  much  smaller  percentage  of 
fat  than  milk  does,  and  the  experience  at  the  London  Zoological 
Gardens  lends  much  weight  to  the  idea  that  the  deprivation  of  fat 
and  proteids  from  the  diet  of  young  animals  is  a  most  important 
factor  in  the  production  of  rickets. 

But  bad  hygienic  surroundings  and  improper  food  or  wholly  in- 
suf^cient  diet  are  not  the  only  factors,  because  thousands  of  chil- 
dren grow  up  every  year  under  these  conditions  without  becoming 
in  the  least  rhachitic. 

Rickets  and  Syphilis. — The  subject  of  the  identity  of  these  two 
affections  must  be  passed  over  very  briefly  as  having  only  an  inci- 
dental interest  in  this  treatise.  The  present  view  rather  regards 
the  diseases  as  separate  ones  and  syphilis  as  an  indirect  cause  of 
rickets  in  impairing  the  general  constitution.'  Pini,  for  example,  in 
4,176  cases  of  rickets  did  not  find  syphilis  as  an  etiological  factor 
in  a  single  case.  The  more  common  experience  is  to  find  a  small 
proportion  of  syphilitics  among  rhachitic  children;  e.g..,  Kassowitz 
in  100  rhachitic  children  saw  3  with  syphilis. 

Recent  opinion  is  best  formulated  in  the  conclusions  of  Cazin 
and  IscovescoMn  a  recent  investigation  of  the  subject.  Their  con- 
clusions were  that  the  bony  lesions  in  the  two  conditions  are  either 
quite  different  or  are  common  to  other  diseases.  Syphilitic  bones 
very  rarely  present  the  spongy  tissue  peculiar  to  rickets,  and  rha- 
chitic bones  never  show  the  osteophytes  of  syphilis.  So  that  ana- 
tomically the  two  processes  are  quite  distinct,  although  syphilis 
may  precede,  or  be  contemporaneous  with  rickets.^ 

Malaria  has  been  claimed  by  Oppenheimer"*  as  the  main  cause  of 

^  Ranke  :    Int.  Med.  Cong.  1881,  vol.  iv. 

^  Cazin  and  Iscovesco  :  Arch.  Gen.  de  Med.,  Sept.,  1887. 

3  Lannelongue,  Soc.  de  Chir.,  1881,  p.  370,  1883,  p.  4. — Poncet:  Bull,  de  la  Soe. 
Anatomique,  1874. — Kassowitz:  "Die  Syph.  als  die  Ursache  der  Rachitis,"  Int.  Cong., 
London,  1881,  vol.  iv. — Taylor:  "Syphilitic  Lesions  of  the  Osseous  System  in  Infants 
and  Young  Children,"  London,  1875. — Parrot:  Bull.  delaSoc.  de  Chir.,  Paris,  1883,  174. 
— Despres:  Bull,  dela  Soc.  de  Chir.,  April  5th,  1883. — Magitot:  Trans.  Int.  Med.  Cong., 
vol.  iv.,  1881. — Capitan;  Bull,  de  la  Soc.  de  Chir.,  ix.,  322. — Capistrel:  "  Cont.  a  I'Etude 
de  I'Etiol.  du  Rachitisme,"  These  de  Lille,  June  21st,  1883. — Gibert:  Soc.  de  Chir.,  1883. 
— Girard:  Revue  de  la  Suisse  Romande,  July  5th,  1883. — Pini:  Semaine  M  d.,  1885,  p. 
325. — Gaillard:  France  Med.,  Jan.  7th,  18S6,  p.  14. — Discussion  Int.  Med.  Cong.,  1881, 
p.  52,  vol.  iy. 

^  Deutsches  Archiv  f.  Klin.  Med.,  188 t,  xxx. 


RICKI'/rS.  621 

rickets,  but  there  is  no  reason  to  take  the  theory  scriou-dy.  Chronic 
tuberculosis  in  the  parents  as  well  as  debility  from  any  cause  im- 
pairing the  nutrition,  may  be  the  cause  of  rickets.  Any  exhausting 
disease  in  the  child  may  be  followed  by  rickets,  while  bronchitis  is 
too  common  a  symptom  of  rickets  to  be  considered  its  cause,  as 
some  writers  would  do.  Finally,  in  certain  rare  cases  no  cause  can 
be  assigned  for  the  occurrence  of  the  affection. 

Symptoms. 

Rickets  is  so  often  the  outcome  of  a  long  period  of  ill-health, 
that  it  is  difificult  to  say  where  rhachitic  symptoms  begin.  In  any 
event  the  disease  is  generally  preceded  by  a  prodromal  period  of 
impaired  health,  fretfulness,  irregularity  of  the  bowels,  capricious 
appetite,  and,  generally,  a  certain  amount  of  cough.  Gradually 
certain  symptoms  occur  which  direct  attention  to  the  possibility  of 
rickets,  but  until  the  distinctive  anatomical  characters  appear,  it  is 
often  very  difficult  to  be  sure  of  the  diagnosis. 

Among  the  more  distinctive  symptoms  of  beginning  rickets  are, 
restlessness  at  night  and  a  tendency  to  throw  off  the  bedclothes. 
The  child  tosses  from  side  to  side  in  the  bed,  but  rarely  cries  out 
or  wakes  up.  Another  symptom  which  should  excite  suspicion  is 
a  tendency  to  profuse  perspiration  at  night,  and  this  sweating  is 
especially  noticeable  about  the  head. 

The  bowels  are  generally  constipated,  but  sometimes  there  is  diar- 
rhcEa  and  constipation.  The  belly  becomes  large  and  distended  with 
flatus,  and  although  the  appetite  may  be  unimpaired,  the  child 
looks  white  and  pasty  and  loses  flesh.  At  this  stage  one  may  en- 
counter the  characteristic  symptom  of  general  tenderness  of  the 
body,  but  many  cases  never  present  this  symptom.  This  tender- 
ness is  sometimes  confined  to  the  bones  and  is  manifested  only  on 
deep  pressure,  while  at  other  times  the  muscles  are  exquisitely 
tender  all  over  the  body,  and  the  gentlest  effort  to  lift  the  child 
may  cause  him  to  shriek  with  pain.  This  symptom  disappears 
readily  under  treatment. 

The  so-called  "  paralysis  of  rickets  "  is  at  times  an  accompani- 
ment of  this  stage,  and  is  generally  brought  to  the  parent's  notice 
by  the  child's  inability  to  walk  or  sometimes  to  stand.  At  other 
times  it  may  be  more  severe  and  take  the  form  of  inability  to  use 
the  arms  as  well  as  the  legs.  There  is  no  permanent  lesion  of  the 
nervous  system  in  these  cases,  and  a  careful  examination  in  the 
recumbent  position  shows  that  the  child's  muscular  movements  are 
but  little  impaired.  The  disability  is  to  be  attributed  to  the  mus- 
cular weakness  and  the  bone  tenderness,  particularly  to  a   perios- 


622  ORTHOPEDIC  SURGERY. 

teal  tenderness  at  the  muscular  insertions.'  The  electrical  reac- 
tion is  normal,  the  reflexes  are  not  afi^ected,  and  recovery  is  certain 
if  the  child  lives. 

This  pseudo-paralysis,  spoken  of  also  as  Parrot's  disease,  is  an 
early  symptom  of  rickets,  and  as  a  rule  precedes  any  marked  osse- 
ous change,  which  adds  to  the  difficulty  of  its  recognition.  The 
most  difificult  affection  from  which  to  distinguish  it  is  the  disability 
due  to  simple  weakness  in  non-rhachitic  children,  but  the  distinc- 
tion is  not  one  of  any  practical  importance. 

In  rickets  the  urine  is  large  in  amount  and  loaded  with  phos- 
phates. Fever  is  most  often  absent  or  due  to  some  complication, 
such  as  bronchitis.  The  very  frequent  occurrence  of  bronchitis 
may  be  again  alluded  to,  and  convulsions  may  occur  at  any  stage  of 
the  disease,  especially  where  there  is  any  tendency  to  craniotabes. 

In  certain  cases  these  symptoms  are  all  so  acute  that  some  writ- 
ers would  make  them  a  separate  class  under  the  head  of  acute 
rickets;  but  the  anatomical  lesions  and  the  symptoms  are  the  same, 
except  for  their  greater  severity,  and  they  seem  to  belong  clearly 
enough  to  the  same  group  as  the  slower  cases,  except  for  a  certain 
group  of  cases  which  seem  to  be  a  combination  of  scurvy  and  rick- 
ets.^    Recovery  is  common. 

Changes  in  the  Bones. — Some  time  after  these  general  premonitory 
symptoms  the  changes  in  the  osseous  system  begin  to  be  evident. 
Enlargement  of  the  epiphyses  appears,  especially  at  the  wrists  and 
anterior  ends  of  the  ribs.  Enlargement  of  the  lower  end  of  the 
radius  and  ulna  is  practically  universal,  whereas  enlargement  of 
the  lower  end  of  the  tibia  and  fibula  occurred  in  only  400  out  of 
1,000  cases. ^  These  enlargements  do  not  involve  the  joints.  At 
the  ribs  one  finds  the  "  rosary,"  a  series  of  bead-like  enlargements 
easily  felt  at  the  junction  of  the  cartilages  and  the  ribs,  and  a  small 
degree  of  epiphyseal  enlargement  is  easily  detected  here,  and  not 
likely  to  be  mistaken  for  anything  else.  When  these  changes  have 
occurred,  the  bones  have  already  softened  and  curvatures  of  the 
long  bones  and  deformities  of  the  spinal  column  have  begun.  In 
the  deep-seated  epiphyses,  like  the  hip  and  shoulder,  one  does  not 
notice  the  change ;  but  at  the  wrist  it  is  most  noticeable  and  the 
figure  gives  the  characteristic  shape. 

The  proliferating  layer  between  the  epiphysis  and  the  bone  may 
become  so  thick  and  so  soft,  that  separation  of  the  epiphysis  and 
much  consequent  deformity  may  occur;  but  such  an  event  is  un- 
common. 

'  H.  W.  Berg  :   N.  Y.  Med.  Rec,  Nov.  i6th,  1881. 

^  Gee:    St.  Barth.  Hosp.  Rep.,  xvii. ;  Barlow:  Med.  Chir.  Trans.,  vol.  Ixvi.,  159. 

3  Reeves:    "  Pract.  Orthopedics,"  p.  14. 


NicKi-yrs. 


623 


The  forces  that  work  to  produce  deformity  in  the  softened 
bones,  are  muscular  action,  gravity,  atmospheric  resistance,  and  the 
pressure  exerted  on  bony  structures  by  growing  organs. 

It  will  be  best  to  consider  seriatim  the  changes  which  rickets 
produces  in  the  different  parts  of  the  body. 

In  the  head,  certain  changes  are  so  constant  that  one  (le]>ends 
much  on  them  for  the  diagnosis.  The  typical  head  of  rickets  has 
a  high,  square,  prow-shaped  forehead,  with  a  decided  prominence  of 
the  lateral  parts  of  the  frontal  bones  (frontal  eminencesj  and  some- 


Fig.  597. — Rhachitic  Hand,  Showing  the 
Epiphyseal  Enlargement. 


Fig.  598. — The  Characteristic  Rhachitic  Head. 


times  of  the  parietal  eminences  as  well.  The  head  is  also  some- 
what lengthened  beyond  the  normal  shape. 

In  general  the  head  appears  to  be  much  larger  in  circumference 
than  it  normally  should  be;  but  such  is  held  by  most  writers  not 
to  be  the  case  ; '  in  fact  these  rhachitic  heads  are  smaller"  as  a  rule. 

Rhachitic  skulls  are  not  necessarily  small,  nor  is  the  high  fore- 
head always  a  misleading  feature.  The  skull  of  Thackeray  was  a 
typically  rhachitic  one,  and  a  statue  of  yEsop  shows  epiphyseal 
enlargement  at  the  wrists,  and  a  characteristic  shape  of  the  skull.  In 
fact,  Trousseau  believed  that  rickets  favored  cerebral  development, 
while  Gee  maintained  that  by  it,  cerebral  growth  was  retarded. 

The  lower  jaw  is  smaller  and  more  rectangular^  than  it  should 
normally  be. 

'  Rep.  of  Lond.  Path.  Soc. ,  Lancet,  ii. ,  iSSo,  1,017. 
-  Patholog.  Soc.  Trans.,  1881,  Discussion  on  Rickets. 
3  Klinik  der  Padiatrik,  ii.  Bd.,  1S77. 


624  ORTHOPEDIC  SURGERY. 

The  expression  of  the  face  is  inteUigent,  although  the  face  clearly 
shows  the  ill-health  of  the  child,  and  the  superficial  veins  of  the 
scalp  and  face  are  enlarged.  The  anterior  fontanelle,  which  should 
normally  close  at  about  the  eighteenth  month,  remams  widely  open 
and  does  not  ossify  until  perhaps  the  third  year  or  even  later. 
This,  however,  is  not  enough  to  establish  the  fact  that  the  child  is 
rhachitic  until  the  age  of  two  years  has  been  reached.  In  a  case 
of  Gerhardt's  it  was  open  for  nine  years.  It  is  ordinarily  some- 
what prominent,  and  over  it  one  can  hear  in  many  cases,  with  the 
ear  or  stethoscope,  a  systolic  bruit,  to  which  much  diagnostic  value 
was  at  one  time  attached.'  It  is  now  known  to  be  of  no  signifi- 
cance and  to  be  heard  merely  because  membrane  transmits  sound 
more  easily  than  bone.-  The  posterior  fontanelle  sometimes  re- 
mains open  for  months.  The  sutures  also  remain  open  longer  than 
they  should,  and  in  such  cases,  after  ossification,  they  are  apt  to 
show  a  depressed  gutter  of  bone  where  they  have  been;  and  such 
a  depression  is  not  uncommon  at  the  site  of  the  closure  of  a  fonta- 
nelle. Sometimes,  however,  prominence  takes  the  place  of  depres- 
sion. Important  symptoms  relate  to  the  irruption  of  the  teeth ; 
not  only  are  they  late  and  irregular,  but  they  are  imperfect  gener- 
ally, and  unable  to  resist  decay.  On  the  average  ^  the  first  tooth 
appears  about  the  ninth  month,  and  not  only  is  the  interval  be- 
tween the  teeth  longer,  but  the  order  of  appearance  is  often  abnor- 
mal. The  first  dentition  does  not  end  on  the  average  until  the 
third  year.  The  teeth  may  present  the  characteristics  of  the  so- 
called  "  Hutchinson's  teeth/' 

Cranio-tabes. — The  name  cranio-tabes  is  applied  to  an  abnormal 
thinness  of  portions  of  the  parietal  and  occipital  bones  which  yield 
to  gentle  pressure  and  give  the  sensation  of  crackling  parchment.. 
The  affection  is  uncommon  in  the  mild  degree  of  rickets  seen  in 
America.  It  is,  however,  more  often  a  symptom  of  congenital 
syphilis  than  of  rickets.  In  23  per  cent  of  presumably  rhachitic 
children  Baxter  found  cranio-tabes  present,  but  in  three-quarters 
of  these  on  more  careful  investigation  he  demonstrated  the  pres- 
ence of  syphilis.  The  affection,  however,  occurs  in  simple  rickets 
(Vogel,  Steiner,  Gerhardt,  West,  Meigs  and  Pepper). 

Hyperaemia  of  the  brain  and  meninges  is,  of  course,  an  accom- 
paniment of  any  skull  affection  so  severe  as  this,  and  is  also  found 
in  other  bones.  With  this  hyperaemia  comes  the  likelihood  of 
hydrocephalus,  either  external  or  internal,  and  the  accompanying 

^  Fisher,  Rilliet  and  Barthez,  1833. 

^  Lewis  Smith  and  Wirthgen.  , 

3  Schwenke:    "  Ueber  den   Einfluss  der  R.  auf  den  Durchburch  des   Milchgebisses." 
Inaug.  Diss.,  Halle,  1886.  .  . 


A'/CK/rrs. 


625 


cerebral  cluingcs,  so  that  hydrocephalus  becomes  a  complication  of 
rickets  which  is  not  very  rare. 

Hydroccpliabis  from  rickets  does  not  differ  in  aj^pearance  from 
hydrocephalus  due  to  other  causes;  but  one  perfectly  marked 
group  of  cases  is  occasionally  seen  which  the  picture  represents 
where  rickets  and  hydrocephalus  coexist.  A  child  of  a  few  months 
old  is  brought,  perhaps  for  convulsions,  perhaps  on  account  of 
pain  or  bad  health;  and  it  is  noted  that  the  head  is  very  large,  the 
fontanelle  wide  open  and  bulging;  the  arm.s  held  at  right  angles  to 
the  body  axis,  and  the  elbows  flexed;  the  legs  flexed  and  the  thighs 
spread  apart.  There  is,  also,  in  these  cases  likely  to  be  a  kyphosis 
of  the  typical  rhachitic  character,  slight  beading  of  the  ribs,  and 
sufificient  epiphyseal  enlargement  to 
make  it  evident  that  rickets  is  pres- 
ent. The  figure  shows  a  typical  case 
of  this  somewhat  uncommon  variety. 

Deformities  of  the  eJiest  are  among 
the  most  common  produced  by  rick- 
ets and  they  occasionally  exist  with- 
out any  well-marked  signs  of  rickets 
elsewhere.  It  is  not  unusual  to  see 
young  girls  about  the  age  of  puberty 
who  have  discovered  some  inequal- 
ity in  the  chest  or  prominence  of  the 
lower  ribs,  perhaps  ;  but  who  present 
no  other  signs  of  rickets.  In  these 
cases  it  seems  reasonable  to  assume 
that  a  slight  degree  of  bone  soften- 
ing existed  in  childhood  and  passed  away  without  leaving  any 
other  sign  than  the  chest  malformation. 

Deformities  of  the  chest  are  produced  by  muscular  action  of 
the  muscles  connected  with  the  thorax  and  also  by  the  atmos- 
pheric pressure  on  the  thoracic  walls.  In  a  typical  rhachitic  chest 
the  clavicles  are  shorter  and  more  curved  than  they  naturally 
should  be.  The  chest  is  narrow  and  prominent  in  front ;  it  shows 
the  effect  of  lateral  compression,  and  the  sternum  projects  so 
prominently  that  the  name  of  pigeon  breast,  or  pectus  carinatum, 
is  commonly  given  to  it.  The  weakest  part  of  the  chest  cavit}-  is 
at  the  junction  of  the  ribs  and  cartilages,  and  it  is  here  that  the 
chief  yielding  takes  place  and  the  ribs  allow  themselves  to  be 
pressed  in  laterally,  Avhile  the  sternum  is  pushed  forward.  At 
other  times  the  ribs  are  pushed  together  laterally  while  the  ster- 
num is  pressed  back.  Again,  one  side  may  yield  more  than  the 
other  and  a  prominence  of  the  front  part  of  the  ribs  on  one  side  of 
40 


Fig.  599. — Rickets  with  Hydrocephalus. 


626 


ORTHOPEDIC  SURGERY. 


the  sternum  may  be  the  only  deformity.  The  diaphragm's  attach- 
ment may  be  easily  seen  in  severe  cases  by  the  encircling  depres- 
sion of  the  ribs  where  its  inspiratory  action  has  pulled  upon  them 
and  they  have  yielded.  This  is  at  the  junction  of  the  sternum  and 
ziphoid  cartilage.  The  prominence  of  the  abdomen,  which  is 
almost  universal  in  well-marked  rickets,  adds  to  the  deformity  of  the 
chest  by  the  elevation  of  the  lower  ribs,  on  account  of  the  underly- 
ing distention.  When  the  abdominal  distention  disappears,  this 
flaring  of  the  lower  part  of  the  ribs  is  sometimes  left  behind. 

Kyphosis. — A  very  common  deformity  of  the  spinal  column  due  to 
rickets  is  a  bowing  backward ;  a  gradual  bowlike  curve  (involving 

the  dorsal  and  lumbar  re- 
gions). It  is  a  uniform  flex- 
ion of  the  whole  column  and 
is  most  prominent  at  the 
junction  of  the  dorsal  and 
lumbar  regions.  This  atti- 
tude seems  the  result  of  a 
long  continued  sedentary 
position  with  a  weakness 
and  tenderness  of  the  mus- 
cles which  fail  to  hold  the 
spine  in  the  erect  position. 
Rhachitic  children,  as  a 
rule,  learn  to  walk  late,  and 
this  peculiar  flexion  seems 
a  persistence  and  exagger- 
ation of  the  position  which 
the  spine  naturally  assumes 
in  young  babies,  who  are 
propped  up  in  the  sitting  position.  The  prominence  of  the  ver- 
tebral spines  at  this  place  is  often  quite  sharp  and  simulates  Pott's 
disease  most  closely.  It  may  be  noted,  in  passing,  that  this  is  the 
most  common  seat  of  Pott's  disease  (Hueter). 

A  rhachitic  spine  should  be  flexible  to  passive  manipulation,  how- 
ever much  it  may  be  curved,'  but  occasionally  much  muscular  irrita- 
bility accompanies  this  condition,  and  one  sees  at  times  cases  of 
rhachitic  curvature  of  the  spine  where  the  curved  part  of  the  spine 
is  inflexible  to  manipulation.  In  these  cases  where  the  child  is  laid 
on  its  face  (as  described  under  Pott's  disease)  and  lifted  by  its  legs 
to  test  the  flexibility  of  the  column,  the  spine  is  as  rigid  as  it  can 
possibly  be;  the  muscles  stand  out  like  cords  on  each  side  of  it  and 
firmly  maintain  the  kyphosis. 

^Reeves:    "  Practical  Orthopedics,"  p.  113. 


Fig.  6oo.- 


-Rhachitic  Curve  of  Spine;  also  Characteristic 
Knlargement  of  Epiphyses  at  Wrist. 


A'/chicrs. 


627 


Scoliosis  is  a  common  deformity  due  to  rickets,  which  has  alrearly 
been  considered  in  Chai)ter  II. 

Lordosis  is  the  third  of  the  common  deformities  due  to  rickets, 
and  gives  rise  to  a  characteristic  attitude,  the  importance  of  which 
is  much  overlooked.  Lane  '  has  called  attention  to  it  in  a  very 
able  paper.  He  demonstrates  the  fact  that  owing  to  the  bowed 
position  which  the  spine  assumes  in  young  children  with  rickets, 
the  sacrum  is  necessarily  flexed  upon  the  iliac  bones  to  compensate 
for  the  great  dorsal  curve  backward.  A  continuance  of  this  posi- 
tion leads  to  its  becoming  more  or  less  permanent,  so  that  when 
the  child  stands,  the  pelvis  necess- 
arily is  rotated  backward  on  a  trans- 
verse axis  to  compensate  for  the  ro- 
tation forward  of  the  sacrum  already 
alluded  to  and  the  lumbar  spine  is 
sharply  curved.  The  backward  ro- 
tation of  the  pelvis  necessarily  makes 
a  tension  upon  the  ilio-femoral  liga- 
ments, so  that  the  patient  finds  it 
more  easy  to  stand  with  the  thighs 
somewhat  flexed,  a  position  which 
has  an  influence  in  the  production 
of  knock-knee  and  bow  legs. 

One  other  factor  occasionally  adds 
to  this  appearance  of  lordosis.  The 
very  large  size  of  the  belly  requires 
a  certain  amount  of  counteracting 
force  whi'ch  the  child  gets  by  leaning 
back,  just  as  a  pregnant  Avoman  does 
when  the  abdomen  begins  to  en- 
large. 

The  RJiacJiitic  Attitude. — The  atti- 
tude of  a  child  affected  with  well-marked  rickets,  shown  in  the 
figure,  is  characteristic.  It  exists  in  nearly  all  marked  cases  of 
knock-knee  and  bow  legs  and  sometimes  in  a  less  degree  with 
milder  grades  of  the  affection.  The  child  stands  with  the  legs 
apart,  the  thighs  flexed  and  the  knees  bent,  the  back  is  arched  and 
the  shoulders  thrown  back.  The  cause  of  this  attitude  has  never 
been  quite  clearly  established. 

It  is  undoubtedly  in  a  measure  the  persistence  of  the  infantile 
attitude,  the  position  which  children  assume  who  are  just  learning 
to  walk.  Children  with  rickets  have  weak  muscles  as  well  as  weak 
bones,  and  the  condition   of  such  a  child   approaches   that   of  an 

'  Guy's  Hosp.  Reports.  3d  Series.  No.  29,  p.  32. 


jj,*;tZW      ^^ 


Fig.  601.  Attitude  of  Severe  Rickets,  Showing 
Lordosis  and  Rotation  of  Pelvis. 


628 


OJ^  THOPEDIC  S  UR  GER  V. 


infant,  in  large  measure ;  hence  he  stands  and  walks  with  the  least 
expenditure  of  muscular  force.  This  explains  certain  cases.  Back- 
ward rotation  of  the  pelvis  is  another  factor,  while  a  third  is  found 
in  the  protuberant  abdomen. 

Deformity.of  the  pelvis  is  induced  by  rickets  because  the  body 
weight  is  borne  by  a  bony  arch  which  has  lost  part  of  its  support- 
ing power,  and  bends  under  its  weight.  These  pelvic  deformities 
have  only  a  significance  in  regard  to  obstetric  surgery,  they  occa- 
sion no  trouble  or  noticeable  deformity  in  themselves;  but  in 
females,  when  pregnancy  comes  on,  their  existence  is  a  matter  of 
the  gravest  importance.  The  subject  is  fully  treated  in  all  books 
upon  obstetrics. 

Except  in  very  severe  cases,  the  arm  bones  are  not  seriously 
curved.  The  curvatures  follow  no  especial  rule,  but  generally  they 
are  an  exaggeration  of  the  normal  curves  of  the  bones.     Of   i,ooo 

cases  of  rickets  analyzed 
by  Reeves,  the  clavicles 
were  curved  in  250,  the 
humerus  in  115,  the  ra- 
dius or  ulna  in  only  97, 
while  knock-knee  or  bow 
legs  was  present  in  about 
500  cases.  The  curvature 
of  the  arm  bones  may  be 
due  to  creeping,  but  as  a 
rule  is  the  result  of  mus- 
cular action. 

Fig.  602.  — Rhachitic  Deformity  of  the  Arm  Due  to  Creeping.  T)eformitv     at     the     bin 

may  take  place,  as  described  by  Fiorani,  which  may  give  rise  to 
obscure  symptoms.  In  fifteen  cases  which  he  reports  there  was  a 
decided  limp,  with  more  or  less  shortening  of  the  affected  leg, 
while  the  trochanter  was  thickened,  and  nearer  to  the  crest  of  the 
ilium  than  it  should  be;  but  motion  at  the  joint  was  perfect.  Ap- 
parently the  deformity  was  due  to  a  yielding  of  the  neck  of  the 
femur,  although  the  condition  has  not  been  absolutely  established 
by  autopsy. 

The  rhachitic  deformities  of  the  legs  are  of  such  importance  that 
they  will  be  considered  under  the  separate  headings  of  knock-knee 
and  bow  legs. 

Flat  foot  is  almost  a  universal  accompaniment  of  rickets.  The 
affection  is  considered  under  flat  foot. 

In  general,  the  skeleton  is  not  only  deformed  but  stunted,  and 
persons  who  have  rickets  severely  in  childhood  do  not  reach  aver- 
age size  in  adult  life.     The  osseous  deformities,  as  a  rule,  persist 


RJCKIilS.  629 

to  a  certain  extent  tliroujrh  life.  Notably  is  this  true  of  the  shape 
of  the  skull  and  the  chest  (Fig.  146). 

Laryngismus  stindulus  is  an  occasional  coin[)lication  of  rickets. 
It  is  fortunately  rather  a  rare  affection,  here  at  any  rate,  although 
the  accounts  of  English  and' Continental  writers  would  lead  us  to 
consider  it  more  common  there. 

The  clinical  description  of  this  condition  as  given  by  We.st  is 
accepted  as  classical.  "  The  child  throws  its  head  back,  its  face 
and  lips  become  livid,  or  an  ashy  pallor  surrounds  the  mouth,  and 
slight  convulsive  movements  pass  over  the  muscles  of  the  face. 
The  chest  is  motionless  and  suffocation  seems  impending.  But  in 
a  few  moments  the  spasm  yields,  expiration  Is  effected,  and  the 
crowing  inspiration  succeeds." 

Milder  forms  of  the  affections  are  more  common  here,  and  a 
slight  tendency  to  laryngeal  spasm  may  be  the  only  difficulty. 
There  is  often  noted  in  these  cases  an  irritable  condition  of  the 
tongue  and  mucous  membrane  of  the  mouth,  which  is  very  sensi- 
tive and  responds  to  the  least  stimulus.  It  seems  to  be  associated 
in  many  cases  with  the  occurrence  of  laryngismus  stridulus.' 

Latent  rickets  is  a  term  of  very  doubtful  utility;  it  is  used  chiefly 
in  speaking  of  cases  where  only  one  symptom  or  one  group  of 
symptoms  becomes  evident,  and  it  does  not  seem  to  mark  out  any 
one  type  of  the  disease,  although,  of  course,  it  must  necessarily  be 
applied  only  to  mild  cases ;  but  it  may  be  assumed  that  the  exist- 
ence pf  localized  rickets  is  perfectly  possible,  and  such  a  theory  is 
needed  to  explain  certain  cases  of  bow  legs  in  children,  e.g.,  where 
no  symptoms  of  general  rickets  are  present ;  and  there  is  this  local 
softening  of  the  leg  bones  which  is  not  likely  to  be  due  to  any 
other  than  a  rhachitic  cause. 

Other  complications  which  may  be  noted  as  of  occasional  occur- 
rence are  the  presence  of  zonular  cataract,  when  the  middle  of  the 
pupil  is  left  clear  and  the  outer  part  becomes  opaque.-  Occasion- 
alh"  there  is  much  general  glandular  enlargement  in  rickets,  and, 
as  has  been  seen,  an  enlarged  spleen  is  not  uncommon. 

Diagnosis. 

The  diagnosis  in  fully  developed  rickets  is  a  very  simple  matter, 
but  when  the  affection  is  beginning,  its  recognition  may  be  attended 
with  much  difficulty. 

In  beginning  rickets,  certain  symptoms  are  ver}-  suggestive; 
these  are:  restlessness  and  sweating  at  night,  large  amounts  of 
urine  passed,  and  especially  universal  tenderness  where  acute  artic- 
'  Money:    Lancet,  Jan.,  iSSg.  -  Goodhardt:    "  Dis.  of  CMldren,"  p.  645. 


630  ORTHOPEDIC  SURGERY. 

ular  rheumatism  is  not  manifestly  present.  No  one  of  these  symp- 
toms is,  of  course,  enough  to  establish  the  existence  of  rickets,  and 
as  they  are  all  likely  to  precede  any  definite  anatomical  change 
they  can  only  lead  one  to  suspect  its  existence.  In  well-marked 
cases  the  diagnostic  points  are  the  epiphyseal  enlargement  of  the 
ends  of  the  long  bones,  especially  the  wrists  and  the  sternal  ends  of 
the  ribs;  the  prow-shaped  head;  the  deep,  small  chest  and  the  big 
belly.  Delayed  dentition  and  an  anterior  fontanelle  open  long  be- 
yond the  proper  time  are  equally  characteristic.  If  the  disease  has 
advanced  still  further,  one  often  finds  curvature  of  the  bones  of  the 
legs  and  arms. 

Delayed  dentition  is  so  important  a  sign  in  the  diagnosis  of  rick- 
ets that  it  deserves  especial  attention.  If  no  teeth  have  appeared 
by  the  ninth  month  the  child  is  very  likely  rhachitic,  and  if  no 
teeth  appear  at  the  end  of  the  twelfth  month  the  child  is  almost 
certainly  rhachitic;  but  the  latter  are  extreme  cases  and  excep- 
tional ones.  In  general  the  delayed  appearance  of  the  teeth 
should  direct  attention  to  the  possible  existence  of  rickets.  The 
second  symptom,  which  is  of  equal  value,  is  the  delayed  closure  of 
the  anterior  fontanelle.  If  this  remains  open  until  the  age  of  two 
years,  there  is  little  doubt  that  the  child  has  rickets.  It  should 
normally  close  about  the  eighteenth  or  twentieth  month. 

Delay  in  learning  to  walk  should  also  excite  suspicion  of  the 
presence  of  rickets.  Mr.  Gee  says,  "  a  child  who  is  not  idiotic  or 
weakened  by  some  recent  acute  disease,  and  who  cannot  walk  at 
the  age  of  eighteen  months  is  either  rickety  or  paralyzed."  The 
cough  and  general  tenderness  so  often  associated  with  rickets  are 
apt  to  obscure  the  affection,  inasmuch  as  they  tend  to  mislead 
parents  and  physician. 

Local  bone  softening  in  children  can  be  accepted  as  evidence  of 
"  latent  rickets,"  even  when  the  general  diagnostic  signs  of  that 
disease  are  absent.  In  older  persons  the  nature  of  the  change 
which  gives  rise  to  this  has  not  been  definitely  established,  and  the 
diagnosis  of  "latent-rickets"  must  be  accepted  with  much  reserve* 

DIFFERENTIAL  DIAGNOSIS. 

The  question  of  the  diagnosis  of  rickets  from  hereditary  syphilis 
is  a  matter  of  much  importance. 

There  are  certain  symptoms  found  at  times  in  both  affections. 
These  are  "  Hutchinson's  teeth,"  cranio-tabes,  and  flexible  bones, 
which  are  occasionally  seen  in  syphilis.  Most  cases  of  congenital 
syphilis  present  no  resemblance  to  rickets  and  are  not  to  be  con- 
fused with  it.     In   the  matter  of   differential    diagnosis,  one  relies 


A'/ch'/rrs.  631 

upon  the  facts  that  the  bench'ng  of  bones  in  syphilis  is  rarely  sym- 
metrical, and  it  is  sharp  and  angular,  rather  than  gradual.  It  is,  in 
fact,  more  like  d  fracture  than  a  bend,  and  around  it  one  finds  an 
induration  like  a  callus.  This  bending  is  an  uncommon  symptom 
in  congenital  sy[)hilis. 

If  enlargement  of  the  joints  is  present  in  syphilis,  it  is  not  sharply 
limited  to  the  epiphysis,  but  always  involves  the  shaft  to  a  certain 
extent.  There  is  no  distinction  to  be  made  in  the  notched  teeth  of 
syphilitic  or  rhachitic  children,  and  the  physical  characters  of 
cranio-tabes  are  the  same  in  both  affections.  It  must  be  borne  in 
mind,  however,  that  both  of  these  physical  signs  are  much  more 
frequent  in  syphilis  than  in  rickets.  In  these  cases  one  has  to  rely 
upon  the  coexistent  signs  of  congenital  syphilis,  which  are  the 
aspect  of  the  child,  the  cicatrices  upon  the  skin,  and  the  presence 
of  bony  or  periosteal  lesions  of  the  shafts  of  the  bones  accompanied 
by  osteophytes. 

Acute  articular  rheumatism  would  be  distinguished  from  rickets 
by  the  presence  of  high  temperature,  joint  swelling,  and  tenderness, 
particularly  acute  at  the  joints,  while  the  tenderness  of  rickets  is 
more  often  general.  Among  young  children,  rickets  is  much  the 
more  common  of  the  two  diseases. 

Chronic  bronchitis,  and  gastro-intestinal  catarrh  are  the  affections 
most  commonly  confounded  with  rickets.  This  is  natural  enough, 
because  they  are  not  only  symptoms  of  rickets  themselves,  but 
often  the  cause  of  the  disease.  When  the  latter  affection  is  present 
with  the  bronchitis  or  gastro-intestinal  disturbance,  one  finds  of 
course  delayed  dentition,  beading  of  the  ribs,  enlargement  of  the 
epiphyses,  etc. 

The  condition  induced  by  malnutrition  is  sometimes  hard  to  dis- 
tinguish from  rickets.  Feeble  children  with  large  heads  and  flabby 
muscles  learn  to  walk  late,  and  this  very  fact  often  suggests  the 
presence  of  rickets  and  the  existence  of  rhachitic  paralysis.  In 
general  the  diagnosis  can  be  made  by  the  absence  of  the  character- 
istic signs  of  rickets  ;  but  it  is  not  to  be  made  off-hand.,  but  with 
very  great  care,  and  at  times  it  may  be  necessary  to  wait  for  time 
and  treatment  to  determine  whether  the  child  is  suffering  from  the 
early  stage  of  rickets  or  not. 

From  Pott's  disease  one  often  distinguishes  rhachitic  spinal 
curvature  with  very  great  difficulty.  Young  children  a  few  months 
old  are  constantly  brought  to  the  hospital  on  account  of  a  promi- 
nence in  the  back  and  a  great  deal  of  crying  in  being  lifted  or 
handled.  At  the  junction  of  the  lumbar  and  dorsal  regions  is  an 
angular  prominence  of  the  spinous  processes  involving  several 
vertebrae,  which  is  not  obliterated  when  the  child  lies  on  its  face, 


632 


ORTHOPEDIC  SURGERY. 


and  is  lifted  by  its  feet  from  the  table.  Sometimes  the  constitu- 
tional evidences  of  lickets  are  so  marked  that  the  diagnosis  is  clear, 
and  under  suitable  treatment  the  spine  regains  its  flexibility  and 
its  normal  curves.  At  other  times  the  constitutional  evidences  are 
simply  of  faulty  nutrition.  Pott's  disease,  where  it  occurs  in  young 
children,  beghis  most  often  in  this  location  and  in  this  way.  The 
writers  have  seen  cases  where  doubtful  kyphoses  of  exactly  the 
same  characteristics  have  been  kept  under  observation  and  treat- 
ment, and  one  case  has  proved  to  be  rhachitic,  while  another  devel- 
oped into  clearly  marked  Pott's  disease. 

Rhachitic  kyphosis  is  much  more  common  than  Pott's  disease  in 


Fig.  603.  P,hachitic  Curvature  of  the  Spine  Simulating  Pott's  Disease. 


children  under  eighteen  months,  and  although  the  presence  of 
rickets  does  not  rigidly  exclude  the  possibility  of  Pott's  disease, 
yet  when  the  general  signs  of  rickets  are  present,  even  if  in  ever  so 
slight  a  degree,  it  is  safe  to  assume  that  in  most  cases  the  kyphosis 
will  disappear  under  treatment.  In  doubtful  cases  time  alone  will 
clear  up  the  question.  The  diagnosis,  it  may  be  repeated,  is  often 
one  of  extreme  difficulty,  and  the  presence  of  an  angular  deformity 
in  that  region  of  the  spine,  in  young  children,  is  not  necessarily 
an  evidence  of  Pott's  disease.  It  may  be  permissible  to  mention 
again  that  flexibility  of  the  spine  is  very  often  lost  in  rhachitic 
kyphosis,  and  that  the  rigidity  of  the  lumbar  region  to  passive 
manipulation  is  not  a  sign  upon  which  any  certain  diagnostic  reli- 
ance can  be  placed. 


a'/ca7':ts. 


(^2>l 


Pigeon  breast  due  to  Pott's  disease,  is  often  found  where  there 
is  a  large  deformity  in  the  dorsal  region  of  the  spine,  and  the  bodies 
of  the  vertebrae  have  given  way.  It  assumes  all  kinds  of  shapes, 
but  its  chief  characteristic  is  a  prominence  of  the  lower  end  of  the 
sternum  and  a  lateral  flattening  of  the  chest.  13eading  of  the  ribs 
is  absent  and  it  occurs  only  after  the  knuckle  in  the  spine  is  very 
evident. 

Cranio-tabes  may  be  simulated  by  a  somewhat  similar  thinning 
of  the  skull  produced  by  intracranial  tumors,  as  in  a  case  related 
by  Fagge.'  The  symptoms  of  the  latter  affection  would,  of  course, 
be  present  in  the  form  of  headaches*  vertigo,  and  localized  paralysis. 

Hydrocephalus  from  rickets  is  not  to  be  distinguished  from  other 
hydrocephalus  except  for  the  coexistence  of  rhachitic  signs. 

One  error  in  diagnosis  has  been  made  which  may  be  mentioned 
in  connection  with  the  prominence  of  the  promontory  of  the  sa- 
crum already  alluded  to.  In  sounding  for  stone  in  rhachitic  boys 
this  prominence  has  been  mistaken  for  a  large  encysted  stone  in 
the  bladder. 

Prognosis. 

When  the  disease  is  left  to  itself  it  generally  runs  its  course,  and 
after  a  decided  degree  of  bony  deformity  has  occurred,  the  process 
of  bone  softening  is  spontaneously  arrested,  and  the  bones  harden 
in  their  deformed  condition.  The  individual  so  affected  never 
reaches  full  size  as  an  adult,  and,  of  course,  always  bears  the  marks 
of  the  disease. 

Spontaneous  arrest  of  the  disease  may  take  place  at  any  stage 
without  treatment,  but,  as  a  rule,  in  severe  cases,  not  before  a  serious 
degree  of  bony  deformity  has  been  produced.  A  fatal  issue  may 
be  brought  about  by  the  complications  of  the  disease;  these  are 
bronchitis,  broncho-pneumonia,  diarrhoea,  hydrocephalus,  and 
rarely  amyloid  degeneration  of  the  viscera.  In  untreated  cases  the 
prognosis  is  unfavorable  in  those  which  have  begun  at  an  early 
age;  when  the  disease  is  treated  efifiiciently  the  prognosis,  as  to  life, 
is  always  favorable  unless  some  serious  complication  is  present,  and 
the  disease  is,  as  a  rule,  easily  amenable  to  treatment. 

Unfavorable  prognostic  signs  are,  any  degree  of  h}'drocephalus, 
the  presence  of  much  diarrhoea,  especially  in  a  feeble  child,  and 
the  existence  of  an  enlarged  spleen,  which  suggests  the  enlargement 
of  the  other  viscera.  Although  bronchitis  is  almost  always  present, 
when  it  is  associated  with  ever  so  slight  a  degree  of  consolidation 
of  the  lung,  it  is  an  unfavorable  sign. 


Prin.  and  Pract.  of  Med.,"  vol.  i.,  p.  532. 


634  ORTHOPEDIC  SURGERY. 

The  arrest  of  the  disease  at  an  early  stage  is  most  important,  as 
it  is  highly  desirable  that,  if  possible,  deformity  should  be  avoided. 

The  kyphosis  above  alluded  to  disappears  under  proper  treat- 
ment, but  it  is  liable  to  cause  a  secondary  rotation  of  the  pelvis,  as 
explained  by,  Arbuthnot  Lane.  Lateral  curvature  is  permanent 
when  not  treated.  The  complications  cranio-tabes,  laryngismus 
stridulus,  bronchitis,  diarrhoea,  tenderness,  and  paralysis  improve 
as  the  general  condition  becomes  better,  and  finally  disappear.  As 
a  rule  the  bony  deformities,  such  as  epiphyseal  enlargement,  dimin- 
ish with  growth,  but  remain  through  life  to  a  certain  degree.  It 
may  be  mentioned  that  in  reading  treatises  on  rickets  by  English 
writers,  the  American  reader  must  make  allowances  for  the  greater 
severity  of  the  disease  in  that  climate. 

Treatment. 

The  preventive  treatment  of  rickets  consists  simply  in  the  proper 
feeding  of  any  child  whose  surroundings  are  not  positively  bad. 
It  has  been  seen  that  rickets  almost  never  develops  without  suffi- 
cient dietetic  cause,  and  its  prevention  consists,  therefore,  in  giving 
suitable  food  to  each  child. 

No  rule  can  be  laid  down  definitely  as  to  what  food  may  or  may 
not  cause  rickets;  but  it  must  be  remembered  that  any  food  which 
imperfectly  nourishes  the  child,  either  because  it  is  unsuitable  in 
kind  or  deficient  in  quantity,  may  be  an  exciting  cause  of  rickets. 
And  among  the  more  common  exciting  causes  in  this  community 
may  be  mentioned  the  use  of  condensed  milk  and  certain  patent 
foods. 

If  the  child  is  being  nursed  it  will  be  found  that  the  milk  is 
probably  poor  from  prolonged  lactation.  Of  course,  weaning  is 
clearly  indicated  in  these  latter  cases.  In  the  others,  which  occur 
so  early,  the  mother's  condition  must  be  attended  to  and  her  milk 
supplemented  or  replaced  by  humanized  cow's  milk,  if  there  is 
reason  to  believe  that  its  condition  cannot  be  immediately  im- 
proved by  the  treatment  of  her  general  health.  If  a  rhachitic  child 
is  being  fed  on  the  bottle,  almost  invariably  it  will  be  found  that 
other  food  is  being  given;  for  careful  bottle  feeding  will  not  cause 
rickets.  Of  course  other  food  must  be  cut  off  and  the  most  rigid 
system  of  cleanliness  be  enforced  in  the  management  of  the  nurs- 
ing bottle.  The  ordinary  nursing  bottles  with  long  glass  and  rub- 
ber tubes  cannot  be  kept  clean  and  should  be  discarded  in  favor  of 
a  common  rubber  nipple  which  can  be  applied  to  any  bottle,  and 
frequently  changed.  The  most  careful  asepsis  in  the  matter  of 
food  is  a  most  important  matter. 


A'/CklCTS.  635 

If  diarrhoea  and  vornitin^r  arc  present,  lliey  should  be  treated 
first  by  the  same  metliods  that  would  be  uscfl  in  the  treatment  of 
these  affections  if  they  alone  were  present. 

The  first  part  of  the  treatment  of  rick'cts  is  then  to  place  the 
child  upon  food  suitable  to  its  age  and  condition.  For  what  this 
food  should  be  the  reader  is  referred  to  works  on  the  diseases  of 
children.  In  addition  to  this  diet  it  is  desirable  to  give  to  rhachi- 
tic  children  of  over  six  months,  meat  juice  or  raw  beef  in  small 
quantities. 

The  earlier  in  the  disease  that  the  case  is  seen,  the  more  import- 
ant is  the  regulation  of  the  food.  In  cases  where  the  process  is 
nearly  ended,  it  matters  little  what  the  child  eats  except  in  so  far 
as  it  influences  his  general  condition. 

Drug  treatment  is  manifestly  secondary  in  importance  to  care- 
ful regulation  of  the  diet  and  hygiene. 

A  remedy  much  advocated  in  the  treatment  of  rickets  is  phos- 
phorus, and  especially  is  this  extolled  by  German  writers  who  as- 
cribe to  it  almost  a  specific  action.  It  is  given  in  doses  of  yJ  ^^  to 
yl^o  of  a  grain  three  times  a  day,  and  in  two  or  three  weeks  it  is 
said  that  marked  improvement  may  be  seen.'  Laryngismus  strid- 
ulus, cranio-tabes,  etc.,  are  said  to  be  at  once  influenced  by  it.  It 
is  most  easily  administered  in  oil,  most  often  cod-liver  oil,  but  it  is 
also  available  in  pill  form,  or  it  may  be  dissolved  in  sweet  almond 
oil. 

Kassowitz  is  of  the  opinion  that  rhachitis  results  from  an  abnor- 
mally increased  vascularization  of  the  bone-making  tissues.  Weg- 
ner  reports  as  a  result  of  a  series  of  experiments  upon  animals,  the 
opinion  that  phosphorus  given  in  small  doses  for  a  length  of  time 
gives  rise  to  a  diminution  in  the  amount  of  the  medullary  tissue, 
and  arrests  the  normal  transformation  of  osseous  tissue  into  me- 
dullary cells,  while  large  doses  cause  the  reverse  condition,  namely, 
an  increase  in  the  medullary  transformation,  such  as  an  artificial 
osteo-malacia.  Kassowitz,  therefore,  has,  in  a  number  of  five  hun- 
dred and  sixty  patients,  administered  phosphorus  with  beneficial 
results,  for  instance,  a  diminution  of  the  nervous  symptoms,  spasm 
of  the  glottis,  restlessness,  sleeplessness,  and  an  imiprovement  in 
the  ability  to  v/alk,  and  in  the  general  condition  of  the  patient,  as 
manifested  by  an  increase  in  weight  and  appetite.  The  phos- 
phorus is  administered  with  cod-liver  oil  in  from,  half  a  teaspoon- 
fulto  two-teaspoonful  doses  daily,  of  a  mixture  of  o.oi  of  phos- 
phorus to  1 00.0  of  cod-liver  oil ;  or  in  older  children  the  medicine 
can  be  given  in  pills,  commencing  with  a  dose  of  half  a  milligramme.- 

'  Toeplitz  and  Kassowitz:    Cent.  f.  Chin,  1SS7,  No.  10. 
=  Z.  f.  Klin.  Med.,  1SS3,  vii.,  36. 


636 


OK  THOPEDIC  S  URGER  Y. 


Jacobi  prescribes  the  officinal  oleum  phosphoratum  of  the  U.  S. 
Pharmacopoeia,  which  is  a  i-per-cent  solution.  Hartwig,  who  is  an 
enthusiastic  advocate  of  the  treatment  of  rickets  by  phosphorus, 
advises  intermissions  in  the  treatment  for  a  month  at  a  time  to 
prevent  granular  degeneration  of  the  liver,  a  danger  which  has 
been  pointed  out  by  Wegner. 

Meyer '  reports  favorable  results  of  treatment  by  phosphorus  in 
ninety-two  cases  of  rickets. 

The  experience  of  the  writers  has  not,  however,  been  in  accord 
with  these  views.  Phosphorus  has  been  tried  faithfully,  but  its 
results  have  been  in  many  cases  unsatisfactory;  and  in  general, 
the  results  of  the  treatment  were  by  no  means  so  striking  as  for- 
eign writers  have  described.  Often  the  drug  would  be  given  for  a 
long  time  without  any  perceptible  effect,  and  again  its  use  was  at- 
tended by  diarrhoea  and  gastric  irritation.  Dr.  Snow,  of  Buffalo, 
who  has  been  a  recent  attendant  at  the  clinic  of  Kassowitz,  says, 
with  regard  to  the  phosphorus  treatment:-  "  I  have  frequented  his 
clinic  at  Vienna  and  failed  to  observe  that  his  patients  did  better 
than  under  other  methods  of  treatment." 

The  syrup  of  the  iodide  of  iron  has  proved,  in  the  experience 
of  the  writers,  the  most  useful  of  the  many  drugs  advocated  in  the 
treatment  of  rickets.  It  has  seemed'to  yield  better  results,  in  con- 
junction with  careful  hygienic  treatment,  than  either  the  prepara- 
tions of  phosphorus  or  of  phosphate  of  lime.  The  iron  should  be 
given  in  small  doses  three  times  daily,  about  one  drop  for  each 
year  of  the  child's  age,  and  continued  for  months.  With  a  careful 
regulation  of  the  diet  and  the  administration  of  the  iron,  one  will 
see  in  most  cases  a  marked  improvement  in  the  child's  condition 
within  two  or  three  weeks;  and  in  general  the  improvement  is  pro- 
gressive. The  wine  of  iron  is  much  used  in  England  and  the 
citrate  of  iron  and  quinine  is  also  advocated.  The  syrup  of  the 
iodide  is  a  disagreeable  preparation  to  take,  but  children  are  rarely 
disturbed  by  it,  and  it  seems,  if  one  may  judge  empirically,  to  have 
a  better  action  than  the  other  preparations  of  the  metal. 

Lime  is  a  remedy  very  much  advocated  in  the  treatment  of  rick- 
ets, and  it  is  generally  given  in  combination  with  phosphoric  acid, 
either  as  powdered  phosphate  of  lime,  or  the  syrup  of  the  hypo- 
phosphites,  or  syrup  of  the  lacto-phosphate.  Its  use  rests  rather 
upon  a  theoretical,  than  an  empirical  basis,  and  one  is  apt  to  be 
disappointed  in  its  working  as  a  drug.  It  is,  however,  desirable  to 
administer  lime  in  the  food  in  some  way  during  convalescence;  but 
the  administration   of  lime  water  seems  of  little  use  unless  there 

'  Meyer:    Inaug.  Diss  ,  Kiel,  1885;  Cent.  f.  Chir.,  1885,  27,  475. 
^  N.  Y.  Med.  Record,  June  15th,  1889,  654. 


KfCKI'/rS.  637 

is  reason  to  believe  that  the  contents  of  the  stomach  are  unduly 
acid.  Parrish's  chemical  food  is  an  accefitable  and  efficient  way  of 
doing  this. 

Cod-liver  oil  is  of  the  greatest  use  both  alone  and  in  connection 
with  other  treatment.  It  supplies  the  fat  which  has  probably  been 
lacking  in  the  diet,  and  its  value  in  any  condition  induced  by  mal- 
nutrition is  undoubted.  It  is  particularly  well  borne  by  children, 
who,  unlike  adults,  do  not  object  to  its  taste  and  smell.  It  should 
ordinarily  be  given  clear  in  doses  of  from  one  to  four  teaspoonfuls, 
about  an  hour  after  meals,  as  at  that  time  the  digestion  of  fats  is 
most  active  and  there  is  less  danger  of  regurgitation.  Occasionally 
the  emulsions  seem  to  be  better  borne,  but  their  Indk  is  of  course 
an  objection  to  them.     Lewis  Smith  advocates  this  prescription  : 

B    01.  morrhuae,  ......  :  vi. 

Syr.  calcis  lacto-phosphatis,  • 

Ac],  calcis, aa   3  iij. 

M.   Sig.    3  i.  or  ij.  three  times  daily. 

One  other  method  of  administration  which  is  often  of  undoubted 
benefit,  is  to  have  the  oil  rubbed  into  the  legs  and  abdomen  each 
night  with  the  warm  hand.  Sufficient  oil  is  absorbed  to  do  good 
and  the  method  is  not  objectionable  if  the  oil  is  carefully  washed 
off  in  the  morning. 

The  following  prescription,  advocated  and  used  very  extensively 
by  Lesser,  is  very  useful  in.  the  acute  stages  of  rickets. 


^    Tinct.  rhei  vini, 

, 

. 

. 

20. 

Pot.  acet., 

. 

10. 

Vini  antimonii. 

5- 

M.  Sig.   In  the  ist 

week,  . 

8  to 

10 

d 

rops  t. 

i.  d. 

"  2d 

<< 

12 

u 

" 

"3d 

(< 

15 

" 

(< 

"  4th 

(( 

18 

i( 

(< 

"  5th 

(< 

20 

il 

(( 

The  use  of  wine  or  spirits  in  small  quantities  is  advisable  in  the 
case  of  children  whose  general  condition  is  poor  and  whose  circula- 
tion is  feeble. 

Finally  one  finds  a  long  list  of  drugs  which  are  advocated  by 
various  writers.  Iron  in  all  its  forms  and  quinine  are  used,  and 
Eustace  Smith  advocates  tannin,  in  doses  of  one-half  of  a  grain  to 
a  grain,  from  which  he  has  seen  much  benefit.  Treatment  by  an- 
timonial  and  mercurial  preparation  is  not  in  vogue. 

The  complications  of  rickets  are  to  be  treated  much  as  if  they 
were  independent  affections.     Antacids  are   most    useful    for    the 


638  ORTHOPEDIC  SURGERY. 

diarrhoea,  especially  rhubard  and  soda,  or  some  preparation  of 
magnesia;  possibly  it  may  be  so  severe  as  to  require  opium.  The 
other  complications  are,  for  the  most  part  best  treated  by  attack- 
ing the  disease  itself. 

Hygiene  and  General  Surroundings. — Rhachitic  children  should  be 
bathed  daily,  preferably  in  salted  water,  and  rubbed  vigorously. 
Warm  woollen  clothing  should  be  worn  and  they  should  go  out 
daily.  Especial  care  should  be  taken  to  keep  them  in  sunny,  well- 
ventilated  rooms;  their  meals  should  be  regular,  and  they  should 
be  obliged  to  eat  slowly.  The  bowels  should  be  watched  and  kept 
regular  by  castor  oil,  fluid  extract  of  cascara  sagrada,  liquorice 
powder  or  some  other  simple  aperient;  and,  every  care  should  be 
paid  to  keeping  the  child's  general  condition  as  good  as  possible 
in  every  way. 

The  hygienic  treatment  of  florid  rickets  is  the  most  rational  and 
successful.  The  seashore  hospitals,  now  established  in  Italy, 
France,  Germany,  and  America,  provide,  with  proper  nursing,  air, 
and  food,  the  best  prophylactic  against  rickets.  In  some  of  the 
large  cities  in  Italy,  institutions  similar  to  those  in  America  known 
as  "  day  nurseries  "  have  been  provided  for  the  daily  reception  and 
treatment  of  rhachitic  children,  with  proper  arrangements  for  bath- 
ing and  fresh  air.  Marked  improvement  is  reported  in  the  cases 
treated  in  these  institutions. 

The  discussion  of  the  operative  and  mechanical  treatment  of 
rickets,  will  be  taken  up  under  the  head  of  knock-knee  and  bow 
leers. 


CHAPTER     XX. 
KNOCK-KNEE    AND    BOW    LEGS. 

Knock-Knee.— Occurrence  and  Etiology. — Symptoms. — Diagnosis. — Prognosis. 
— Treatment. — Expectant. — Mechanical. — Operative. — Bow  Legs.*— Occur- 
rence.— Causation. —  Symptoms. —  Diagnosis. —  Prognosis. —  Treatment. — 
Expectant. — Mechanical. — Operative. 

Knock-knee. 

Knock-knee,  or  gcmi  valgum,  is  the  name  applied  to  an  internal 
angular  prominence  of  the  knee,  in  which  the  bones  of  the  leg 
form  an  abnormal  lateral  angle  with  the  bones  of  the  thigh,  and 
this  angle  opens  outward. 

This  condition  is  also  known  in  English  as  in-knee;  in  Latin  as 
genu  introrsum;  in  German  as  Knickbein,  X-bein,  Backerbein, 
Ziegenbein,  Kniebohrer,  Knieng,  and  Schemmelbein ;  in  French  as 
genou  cagneux,  genou  en  dedans,  and  in  Italian  as  ginocchio  torto 
air  indentro. 

Occurrence  and  Etiology. — The  deformity  is  one  of  common  occur- 
rence, but  not  so  common  as  bow  legs.  In  2,650  cases  of  surgical 
disease  in  children  coming  to  the  Out  Patient  Department  of  the 
Boston  Children's  Hospital,  there  were  only  100  cases  of  knock- 
knee,  while  there  were  170  cases  of  bow  legs. 

In  6,400  cases  of  surgical  disease  in  children  treated  at  the -New 
York  Orthopedic  Hospital  and  Dispensary,  there  were  270  cases  of 
knock-knee  and  400  cases  of  bow  legs;  and  in  general  this  relative 
frequency  holds  good.  Both  deformities  affect  boys  more  often 
than  girls. 

Knock-knee  is  a  deformity  which  becomes  evident  in  early  child- 
hood or  at  adolescence.  In  rare  cases  it  has  been  noted  at  birth 
(Dittel),  but  it  appears  for  the  most  part  shortly  after  the  children 
learn  to  walk,  although  by  no  means  is  its  appearance  necessarily 
delayed  until  that  time ;  for  the  deformity  is  sometimes  seen  in 
infants  in  arms ;  but  always  in  these  cases  it  is  associated  with  gen- 
eral rickets.  Its  regular  appearance,  then,  is  at  one  of  two  distinct 
periods,  between  the  ages  of  two  and  four,  or  between  the  ages  of 
twelve  and  eighteen.      Exceptional  cases  occur  at  any  age. 


640 


ORTHOPEDIC  SURGERY. 


Knock-knee  occurring  in  the  first  period  named  is  almost  always 
associated  with  general  rickets,  and  no  obscurity  exists  as  to  its 
cause,  and  this  is  spoken  of  by  many  writers  as  gemt  valgum  rhachi- 
Hcum^  to  distinguish  it  from  the  form  occurring  at  puberty,  which 
is  spoken  of  as  genn  valgum  staticum  sive  adolescentium.  Many 
efforts  have  been  made  to  identify  this  later  form  also  with  rickets, 
as  by  Mikulicz  and  others,  who  would  consider  it  a  local  rhachitic 
process,  a  form  of  "  latent  rickets."  But  such  an  assumption  has 
as  yet  no  proper  anatomical  basis. 

The  form  of  knock-knee  occurring  in  adolescence  especially 
affects  persons  whose  occupation  compels  them  to  be  most  of  the 
time  in  a  standing  position,  and,  as  a  rule,  those  affected  are  indi- 
viduals of  feeble  physique. 

Other  cases  of  knock-knee  are  produced  as  a  late  result  of  mus- 
cular paralysis.  Fractures  about  the  joint  and  de- 
structive ostitis  are  also  causes  of  knock-knee  in  ex- 
ceptional cases. 

How  these  pathological  factors  find  their  clinical 
expression  in  an  angular  deformity  of  the  knee  will 
be  considered  in  the  following  section. 

Mechanical  Prodtiction  of  Knock -knee. — The  nor- 
mally formed  human  being  in  the  upright  position 
stands  with  a  certain  amount  of  knock-knee.  The 
femurs  form  an  angle  of  15°  with  each  other  and 
sometimes  more,  and  as  a  result  of  this  oblique  direc- 
tion, the  inner  condyle  of  the  femur  must  be  longer 
than  the  outer.  This  is  evident  from  a  glance  at  the 
figure.  This  excess  of  length  must  vary  with  the 
width  of  the  pelvis  and  the  obliquity  of  the  femurs. 
Clark  estimated  that  the  internal  condyle  of  the  femur  was  nor- 
mally longer  than  the  external  by  a  quarter  of  an  inch,  and  Holden 
estimates  it  as  one-half  an  inch  longer  under  normal  circumstances. 
The  chief  cause  of  the  deformity  seems  to  be  a  statical  one,  ex- 
cept in  those  early  cases  due  to  rickets  where  weight  has  not  been 
borne  upon  the  feet.  Here  its  cause  lies  in  an  unequal  growth  of 
the  epiphysis  of  the  femur  or  in  a  bend  of  the  lower  part  of  the 
shaft  of  the  femur  produced  by  great  softness  of  the  bone  and 
muscular  action  pulling  upon  the  bone  and  causing  it  to  curve. 

When  a  normally  formed  person  stands  erect  with  the  heels  to- 
gether, if  a  plumb  line  be  dropped  from  the  head  of  the  femur,  it 
will  be  seen  to  fall  outside  of  the  centre  of  the  knee-joint;  and  this 
will  happen  to  a  greater  extent  in  the  female  than  in  the  male. 

It  is,  therefore,  evident  that  the  external  condyle  of  the  femur 
and  the  corresponding  facet  of  the  tibia  transmit  more  body  weight 


Fig.  604. — Axis  of 
a  Normal  Leg,  and 
of  one  Affected  with 
Knock-knee. 


h'NOCK-KN /':/':  AND   Ji(J  IV   LI'.GS. 


641 


than  do  the  corresponding  internal   articular  surfaces,  because  the 
centre  of  tjravity  lies  outside  of  the  centre  of  the  joint. 

To  maintain  an  erect  position  with  the  feet  together  recjuires, 
therefore,  muscular  action.  If  the  standing  position  is  to  be  main- 
tained for  a  long  time,  or  for  a  short  time  in  the  case  of  children 
or  feebly  developed  adults,  the  instinctive  disposition  is  to  sub- 
stitute ligamentous  for  muscular  support.  This  can  be  accom- 
plished by  keeping  the  knee  extended  and  separating  and  everting 
the  feet.  It  is  the  attitude  assumed 
by  children  learning  to  walk  and  by 
tired  adults.  In  this  way  the  weight 
comes  upon  the  knee-joint  laterally, 
and  muscular  effort  is  not  needed  to 
keep  the  joint  rigid  in  the  lateral 
plane;  for  that  is  accomplished  by 
the  ligaments.  This  attitude  is  often 
spoken  of  as  "the  attitude  of  rest." 

From  this  position  more  weight 
than  before  is  transmitted  through  the 
external  condyle,  and  less  through  the 
internal  one.  If  angular  deformity 
takes  place,  finally  all  the  weight  is 
transmitted  through  the  external  con- 
dyle. 

Two  inevitable  results  follow  from 
this:  stretching  of  the  internal  lateral 
ligament  and  atrophy  of  the  external 
condyle. 

The  stretching  of  ligaments  when 
subject  to  undue  tension  is  too  famil- 
iar a  pathological  process  to  require 
comment.  The  atrophy  of  bone 
which  is  subjected  to  pressure  and 
strain  has  been  established  clearly 
enough  by  Arbuthnot  Lane.' 

These  factors  tend,  then,  to  produce  and  increase  angular  de- 
formity at  the  knee.  As  the  external  condyle  shrinks  and  the  licr- 
ament  lengthens,  the  angle  between  the  bones  of  the  thigh  and  the 
bones  of  the  leg  increases,  and  with  each  increase  the  bod}-  weight 
acquires  better  leverage  and  m.ore  power  to  do  harm  to  the  yield- 
ing joint.  All  of  which  must  result  in  atrophy  of  the  external 
condyle. 

Although  the  mechanical  forces  just  alluded  to  are  competent  to 


Fig.  605 


'  Lane:    Guy's  Hosp.  Rep. ,  vol.  xxviii. 


41 


642 


ORTHOPEDIC  SURGERY. 


produce  severe  knock-knee,  the  presence  of  rickets  makes  the  con- 
dition much  worse,  for  it  not  only  softens  the  bones,  but  relaxes 
the  ligaments  and  weakens  the  muscles,  as  demonstrated  by  Kas- 
sowitz.  It  is  easy  to  see,  therefore,  how  much  this  process  would 
aid  in  producing  the  deformity  of  knock-knee,  not  only  at  the 
joint,  but  in  the  femur  and  the  tibia,  by  allowing  their  shafts  to 
bend  above  and  below  the  joint,  and  so  making  the  deformity  ex- 
cessive. 

Flat-foot  ordinarily  coexists  in  the  static  genu  valgum  as  well  as 
in  the  rhachitic.  Sometimes  it  must  stand  in  a  causative  relation 
to  knock-knee;  sometimes  it  is  more  the  result  than  the  cause,  but 
commonly  they  are  both  the  results  of  the  same  faulty  attitude, 

assumed  as  a  result  of  muscular 
fatigue  and  weakness.  Flat-foot 
is  more  easily  produced  than  knock- 
knee,  and  is  in  young  adults  very 
much  more  common. 

It  is  proper  to  recognize  the  class 
of  cases  when  the  femur  is  appar- 
ently normal,  but  the  articulating 
surfaces  on  the  head  of  the  tibia 
are  oblique.  This  is  considered  as 
the  common  cause  of  the  deformity 
by  some  writers;  i^\^..  Noble  Smith. 
In  still  a  third  class  of  cases  the 
deformity  is  not  due  so  much  to 
primary  joint  obliquity  as  to  a 
bend  in  the  diaphysis  of  the  femur  or  the  tibia,  just  above  or  just 
below  the  joint.' 

There  are,  then,  three  bony  deformities  found  in  cases  of  knock- 
knee,  viz. : 

(1^)  Difference  in  the  size  of  the  condyles  of  the  femur. 
{h)  Inequality  in  the  articular  facets  of  the  tibia. 
{c)  Bending  of  the  diaphyses  of  the  bones  above  or  below  the 
joint. 

In  severe  cases  the  tibia  is  found  to  be  rotated  outward. 
The  internal  ligaments  are  hypertrophied,  and  the  muscles  and 
tendons  on  the  inner  aspect  of  the  leg  are,  of  course,  stretched. 
The  patella  lies  farther  outside  than  it  should  do.  In  some  it  may 
be  seen  that  the  outward  rotation  of  the  tibia  is  so  marked  that 
a  sort  of  compensatory  inversion  of  the  feet  has  been  acquired 
almost  to  the  condition  of  varus  to  aid  in  keeping  balanced. 

There  are   certain   classical   etiological  theories  which  must  be 

'  Arch.  f.  Klin.  Chir.,  1879,  xxiii. 


Fig.  606. — Severe  Knock-knee  with  Outward 
Rotation  of  the  Tibia. 


KNOCK-KNEI'.    AND    I  SOW   I.I'.GS.  643 

considered  in  tlieir  relation  to  more  recent  ideas  as  to  tlie  jn'odnc- 
tion  of  genu  valgtim. 

The  ligamentous  theory  assumed  either  a  primary  relaxation  of 
the  internal  lateral  ligament  and  a  consecjuent  hypcrtrojjhy  of  the 
internal  condyle  of  the  femur  (Malgaigne,  Stromeyer,  Guerin, 
Blasius,.  etc.),  or  that  the  external  lateral  ligament  was  primarily 
shortened  and  so  induced  pressure  upon  the  externrd  condyle  and 
caused  it  to  atrophy. 

The  muscular  theory  wouUI  find  the  primary  change  in  a  short- 
ening of  the  biceps,  popliteal,  and  tensor  vagin.'e  femoris  muscles; 
or  in  a  relaxation  of  these  same  muscles.  As  in  the  ligamentous 
theory,  there  are  two  factions,  each  diametrically  opposed  to  the 
other.  Among  the  supporters  of  a  primary  muscular  change  as 
the  cause  of  the  deformity  are,  Duchenne,  Jorg,  Bonnet,  Guerin, 
Little,  Adams,  and  Brodhurst.  These  writers  would  regard  the 
bone  changes  as  secondary  to  the  muscular  relaxation  or  contrac- 
tion. 

The  osseous  theory  is  advocated  by  Hiiter,  Annandale,  Ogston, 
Chiene,  Macewen.  Gosselin,  Oilier,  Tillaux,  and  others,  and  it  is 
assumed  that  a  primary  bony  change  is  the  source  of  the  trouble. 
Oilier  proved  experimentally  that  inflammation  of  the  epiphyseal 
cartilage  caused  retarded  growth  of  the  bone  where  it  took  place; 
and  Oilier  and  Gosselin  believed  that  there  was  a  premature  in- 
flammatory synostosis  of  the  external  part  of  the  epiphyseal  carti- 
lage of  the  femur;  and  that  this  caused  retarded  growth  of  the 
external  condyle  of  the  femur. 

Other  upholders  of  the  osseous  theory  would  find  a  rhachitic 
origin  for  all  knock-knee;  the  propriety  of  such  a  proceeding  has 
been  already  considered. 

Mickulicz  would  find  its  cause  in  hyperextension  of  the  tibia  and 
consequent  exaggerated  external  rotation  of  that  bone.  Each  of 
these  theories  was  invented  to  account  for  some  pathological  con- 
dition found  in  knock-knee.  Relaxed  and  shortened  ligaments, 
stretched  muscles,  and  unequal  development  of  the  condyles  are 
all  accompaniments  of  the  deformity;  but  that  seems  no  reason 
to  assign  to  them  a  primary  place  in  the  sequence  of  events,  if  they 
can  be  explained  in  any  more  rational  way.  They  all  have  their 
function  in  the  production  of  the  deformity;  sometimes  one  pre- 
dominates, sometimes  the  other;  but  the  primary  cause  of  them 
all  is  most  often  the  static  one  already  alluded  to. 

Symptoms. — Subjective  symptoms  in  knock-knee  are  almost  al- 
Avays  absent.  .Children  and  adults  tire  more  easily  than  they  should, 
when  they  have  knock-knee,  and  sometimes  pain  and  sensitiveness 
are  complained  of  over  the  internal  lateral  ligament   of  the  knee; 


64^1. 


ORTHOPEDIC  SURGERY. 


but  it  is  not  a  common  symptom.  In  young  children  with  knock- 
knee  and  active  rickets,  locomotion  is  generally  difficult,  while  in 
adult  cases  there  is  less  difficulty  in  walking,  even  in  severe  cases, 
than  would  be  expected  from  the  degree  of  the  deformity. 

The  physical  signs  of  the  affection  are  marked  and  characteristic. 
In  the  standing  position  it  is  noticed  that  the  knees  are  unduly 
prominent  on  the  inside  aspect  of  the  leg,  and  that  the  tibias  di- 
verge so  that  the  feet  are,  perhaps,  only  a  few  inches  apart,  or 
again  a  considerable  distance  in  severe  cases.  In  cases  where  the 
angular  deformity  is  very  great,  the  patients  find  the  easiest  posi- 


FiG.  607.     '  Fig.  608. 

Figs.  607,  608. — The  Varying  Condition  in  Knock-knee,  Showing  a  Mild  and  a  Severe  Case. 

tion  for  standing  is  with  one  knee  behind  the  other,  as  seen  in  Fig. 
609,  so  that  in  this  way  the  feet  may  be  brought  together. 

Rhachitic  patients  generally  stand  with  lordosis  of  the  lumbar 
spine  and  flexion  of  the  thighs  upon  the  trunk,  the  attitude  already 
spoken  of  as  rhachitic. 

The  presence  of  flat  foot  has  been  already  mentioned. 

There  may  be  rotation  of  the  tibia  outward  in  severe  cases. 
Rotation  of  the  tibia  inward  is  still  more  rare,  but  is  sometimes 
met. 

The  gait  of  a  patient  with  double  knock-knee  is  distinctive  and 
necessarily  present  where  the  deformity  exists  to  any  considerable 
extent.  Inasmuch  as  the  knees  overlap  when  the  feet  are  to- 
gether, some  means  must  be  addpted,  on  the  patient!s  part,  to  pre- 
vent the  knees  from  knocking  against  each  other  as  he  carries  one 
leg  forward   past  the   other  in  walking.     If  he  walked  naturally. 


KNOCK-KNI'Ji  AN  J)   JiOW  J.I'AJS. 


^>45 


the  knee  that  was  behind  would  hit  against  llic  front  knee  and  stop 
progression.  This  can  he  avoided  by  throwing  his  body  to  one 
side  while  he  abducts  the  opposite  leg  by  the  force  of  gravity,  and 

so  carries  it  past  the  stationary  leg 
without  knocking  the  knees  together. 
This  must  be  repeated  at  each  step,  so 
that  the  gait  is  a  rolling  one,  consisting 
of  a  series  of  sliglit  lurches,  which  are, 
however,  not   nearly  so   marked  as  in 


Fig.  6oy  — Pio^rebsion  in  Severe  Knock  knee. 


Fig.  6io. — Outward  Rotation  of  Tibia. 


bow  legs  or  congenital  dislocation  of  the  hip ;  while  what  is  par- 
ticularly noticeable  is  the  outward  throw  of  the  leg  when  it  is  being 
brought  forward. 


Fig.  6ii. — Showing-  Sli.8:ht  Knock-knee  Chiefly  in 
the  Left  Leg,  with  Flat-foot. 


Fig.  6i2. — Lateral  Curvature  Resulting  from 
Knock-knee. 


The  gait  is,  moreover,  slightly  modified  by  the  fact  that  in  severe 
cases  the  thighs  and  consequently  the  knees  are  slightly  flexed. 
When  the  deformity  is  unilateral,  the  gait   is  much  less  marked, 


646 


OR  THOPEDIC  S  URGER  Y. 


and  the  bent  leg  is,  of  course,  shorter  than  the  straight  one,  so  that 
the  pelvis  is  oblique  on  that  account.     A  limp  on  the  affected  side 


is  common  when  the  deformity  is  unilateral  and  at  all  severe,  and  a 
throwing  outward  of  the  sound  leg  in  bringing  it  forward  past  the 


K NO CK-KN /■:/<:  AND   BO  IV  LEGS. 


647 


affected  one.  The  affection  of  the  gait  is  generally  slight  in  uni- 
lateral cases.  Lateral  curvature  is  sometimes  induced  by  the  uni- 
lateral deformity,  especially  as  the  knock-knee  is  likely  to  occur,  as 
we  have  seen,  in  patients  whose  muscular  development  is  feeble. 

On  manipulation,  the  knee-joint  is  often  movable  in  a  lateral 
plane  through  an  arc  of  several  degrees.  This  is  especially  com- 
mon in  the  younger  cases,  and   jKjints  to  considerable  laxity  of  the 


k  Knee  fiMin  Severe  Rickets. 


ligaments.  In  these  cases  the  deformity  is,  of  course,  increased 
when  weight  is  put  upon  the  affected  leg,  so  that  in  walking  and 
standing  it  reaches  its  maximum.  The  figure  will  show  how  severe 
may  be  the  deformities  of  the  leg  in  severe  rickets. 

The  angular  deformity  disappears  when  the  knee  is  flexed  to  a 
right  angle,  except  in  cases  where  the  chief  twist  is  in  the  tibia — a 
fact  which  has  given  rise  to  many  theories  which  strive  to  explain 
it.     It  would   seem   to   be   most   easily  accounted   for  by  the  fact 


648 


OR  THOPEDIC  S  URGER  Y. 


that  the  posterior  surfaces  of  the  condyles  of  the  femur  were  not 
so  much  affected,  but  that  the  deformity  was  produced  by  an  alter- 
ation of  the  lower  surfaces  of  the  condyles  alone,  and  that  when 
the  facets  of  the  tibia  ceased  to  articulate  with  them,  the  abnor- 
mality ceased — a  state  of  affairs  which  coincides  very  well  with 
the  static  theory  of  the  production  of  the  deformity  (Fig.  619). 

On  the  other  hand,  a  certain  part  of  the  disappearance  of  the 
deformity  is  due  to  the  fact  that  in  flexion  of  the  thigh  the  femur 
rotates  outward  on  its  own  axis;  a  fact  which  Albert  and  Mick- 
ulicz  bring  forward  as  the  whole  explanation  of  the  disappearance. 
But  if  the  knee  be  flexed  while  the  hip-joint  is  still  extended,  the 
deformity  does  not  entirely  disappear,  though  it  is  very  much 
diminished. 

The  practical  point  is,  that  as  the  deformity  is  most  severe  when 


Fig.  615. — Tracing  of  a  Case  of  Knock-knee 
with  Outlines  of  the  Condyles. 


Fig.  616. — Inequality  of  the  Condyles  Shown  in  Outline 
in  a  Case  of  Severe  Knock-knee. 


the  leg  is  in  the  extended  position,  all  mechanical  treatment  ap- 
plied to  the  correction  of  knock-knee  must  be  to  the  fully  extended 
leg,  for  when  apparatus  allows  the  knee  to  flex,  it  is  imperfect, 
and  loses  a  part  of  its  ef^ciency.  When  the  leg  is  fully  flexed  the 
inequality  in  the  length  of  the  condyles  is  most  evident,  as  seen  in 
outline  from  the  anterior  surface  of  the  thigh.  The  diagram  gives 
an  idea  of  the  amount  of  their  inequality  in  a  case  of  average 
severity.  This  may  be  registered  by  shaping  a  lead  strip  to  the 
lower  surface  of  the  femur  when  the  knee  is  fully  flexed,  and  draw- 
ing an  outline  on  paper  from  the  lead  strip,  which  should  be  stiff 
enough  to  keep  its  shape. 

Secondary  Deformities. — Beside  lateral  curvature  and  flat-foot, 
there  is  seen  at  times  a  condition  of  the  foot  approaching  varus  in 
certain  advanced  cases  of  knock-knee  where  the  deformity  is  severe 
and  a  continual  effort  is  made  to  invert  the  feet  and  so  bring  the 
support  nearer  the  centre   of  the  body.     By  this  means  a  perma- 


KNOCK-KNIU'l  AND    nOW  LliCS. 


649 


nent  inversion  of  the  front  part  of  the  foot  is  acquired,  with  a  cer- 
tain amount  of  contraction  of  the  plantar  fascia  (Fig.  617). 

Hyperextension  of  the  knee  is  Hkely  to  be  induced  in  severe 
cases  of  knock-knee  in  young  adults,  where  it  is  of  long  standing 
and  where  the  ligaments  and  muscles  are  weak. 

Occasionally  one  sees  a  combination  of  knock-knee  and  bow  legs 
in  the  same  subject,  where  the  knock-knee  seems  to  have  been  the 


Fig.  617. — Position  of  Patient  with  Severe  Knock- 
knee;  Standing  Position  Shiowing  Especially 
tlie  Inversion  of  the  Feet. 


Fig.  618. — Position  of  Patient  with  Severe 
Knock-knee  Walking. 


original    deformity    and    the    bow  legs    superadded,  so  that    both 
knock-knee  and  bowing  of  the  tibia  may  exist  in  the  same  leg. 

Methods  of  Measurement  of  the  Deformity. — The  many  compli- 
cated methods  for  the  estimation  of  the  amount  or  degree  of 
knock-knee  seem  superfluous.  Reeves,  Schreiber,  Mikulicz,  Roberts, 
and  others  describe  methods  which  give,  in  degrees  or  some  equiv- 
alent, the  amount  of  angular  deformity.  But  the  simplest  and 
most  reliable  method  of  registration  is  to  have  the  patient  sit 
upon   a  sheet   of  brown  paper  with  the  legs  extended  and  the  feet 


650 


OR  THOPEDIC  S  URGER  V. 


pointing  upward  ;  and  then,  with  a  pencil  held  perpendicularly  to 
the  paper,  to  trace  the  outline  of  the  legs.  No  other  method  can 
give  so  accurate  an  idea  of  the  degree  and  character  of  the  deform- 
ity present,  or  can  afford  so  delicate  a  means  of  watching  and  re- 
cording the  progress  of  the  case.  The  tracings  to  be  considered 
later  were  all  obtained  by  this  simple  method. 


Fig.  619. — Showing  Disappearance  of  Deformity  when 
Knee  is  Flexed. 


Fig.  620. — Severe  Knocli-ltnee  and  Anterior 
Curvature  of  the  Tibia. 


Diagnosis. — The  diagnostic  points  which  mark  the  affection  known 
as  knock-knee  are  an  inward  angular  deformity  at  the  knee  which 
disappears  on  flexion  of  the  leg  upon  the  thigh.  There  is  also  in 
this  position  to  be  noted  a  relative  prominence  of  the  internal  con- 
dyle of  the  femur  in  nearly  all  cases. 

As  to  the  identification  of  the  different  varieties  of  the  affection, 


KNOCK-KNI'lE  AND   HOW  /JCdS. 


6u 


enough  has  already  been  said.  In  children  the  large  proportion  of 
all  cases  are  rhachitic,  while  in  adults  the  purely  static  cause  must 
be  assigned.  It  is  not  in  general  justifiable  to  assunne  rickets  as 
the  cause  of  knock-knee  in  cases  where  there  are  no  distinctive 
signs  of  rickets. 

Paralytic   knock-knee   only  occurs  in    severe   grades  of    paralysis 
and  coexists  with   tali];es  valgus  or  calcaneo-valgus.      Its  diagnosis 


Fig.  621. — INIethod  of  Taking  Tracings. 


is  evident  from  the  wasted  and  contracted  condition  of  the  para- 
lyzed limb. 

Knock-knee  from  destructive  disease  of  the  knee-joint  is  a  result 
of  severe  tumor  albus  and  not  of  the  lighter  grades.  Its  occur- 
rence means  a  destruction  of  so  much  osseous  tissue  that  partial  or 
total  ankylosis  is  present  and  in  most  cases  subluxation  of  the  tibia 
backward,  with  flexion  of  the  knee.  In  a  case  of  such  destructive 
disease  there  has,  of  course,  generally  been  an  abscess  and  there 
are  cicatrices  of  sinuses  to  be  seen.  The  knee  will  present  the 
other  characteristic  diagnostic  signs  described  under  tumor  albus 
of  the  knee. 

Traumatic  knock-knee  is  of  two  kinds:  (^?)  Resulting  from  oste- 


652 


ORTHOPEDIC  SURGERY. 


otomy  for  genu  varum  and  over-correction  of  the  deformity;'  {b) 
Resulting  from  fractures  of  the  condyles  of  the  femur  or  of  the 
articular  facets  of  the  tibia  which  are  liable  to  cause  lateral  mal- 
position of  the  knee. 

There  is  no  ^differential  diagnosis  to  be  considered  in  the  deform- 
ity under  discussion.  Any  condition  at- 
tended by  internal  angular  deformity  of 
the  knee  is  knock-knee,  by  whatever  it  is 
produced,  and  all  that  remains  is  to  de- 
termine the  variety  of  the  deformity. 

Prognosis.-— T\v&  course  of  the  deformity 
when  untreated  is  of  the  greatest  practical 
interest  with  regard  to  the  advisability  of 


Fig.  623. 
Figs.  622,  623. — Static  Knock-knee. 


Fig.  624. — Rhachitic  Knock-knee. 


expectant  or  active  treatment.     The  question  arises  in  every  slight 
case  occurring  in  childhood,  "  Will  the  child  outgrow  the  deform- 


'  The  writers  have  seen  one  or  two  cases  where  an  operation  for  an  outward  bending 
at  the  knee  has  resulted  in  slight  knock-knee.  Such  a  condition  was  probably  brought  about 
by  some  exceptional  softness  of  the  bone  and  is  hardly  to  be  set  down  as  more  than  a  very 
rare  and  unavoidable  sequel  of  the  operation. 


KNOCK- k'NJCK  AN])    noW   /JC(JS. 


653 


ity  ?"  In  severe  cases  it  is  plainly  evident  that  so  much  harm  has 
been  done  already,  and  the  bones  have  come  into  such  faulty  apjjo- 
sition,  that  spontaneous  improvement  is  nf;t  to  be  expected  ;  and 
practical  experience  bears  out  that  conclusion.  Children  with  a 
slight  degree  of  knock-knee  which  is  not  progressive  will  probably 
outgrow  it  without  any  treatment  if  in  vigorous  health.  But  if  the 
deformity  is  moderate  or  severe,  the  chances  are  very  strong  that 


Fig.  625. — Bow  Leg  of  the  Right  Leg,  Knock-knee 
and  Flat  Foot  of  the  Left. 


Fig.  626. — Rhachitic  Knock -knee  and  Bow  Leg 


the  affection  will  remain  stationary  or  more  probabh-  will  become 
worse  as  time  goes  on,  unless  treatment  is  begun. 

Treatment. — The  treatment  of  knock-knee  falls  into  three  divi- 
sions: (I.)  Expectant;  (II.)  Mechanical;  (III.)  Operative. 

I.  The  expectant  method  of  treatment  relies  upon  nature's  efforts 
to  repair  the  deformity;  efforts  which  are  aided  on  the  part  of  the 
surgeon  by  keeping  the  child  off  of  its  feet  to  a  greater  or  less  ex- 
tent, and  by  constitutional  treatment.  There  is  no  question  that 
in  mild  cases  there  is  a  tendency  to  outgrow  the  deformity,  but 
this  tendency  is  at  a  great  disadvantage  mechanically,  except  in 
these  very  slight  cases;  nor  is  it  a  safe  proceeding  to  wait  for  this 


654 


ORTHOPEDIC  SURGERY. 


spontaneous  cure  in  any  marked  case  of  knock-knee.  The  applica- 
tion of  apparatus  does  no  harm  and  aids  and  hastens  a  natural 
cure. 

The  difficult  question  in  the  whole  matter  is  of  course,  which 
cases  can  be  left  to  themselves — a  question  which  cannot  be  an- 
swered categorically. 

An  argument  for  the  spontaneous  outgrowth  of  knock-knee  is 
found  by  some  writers  in  the  rarity  of  adult  cases  which  present 
themselves  at  clinics.  Gibney'  observed  in  six  years  276  cases  of 
genu  valgum  at  the  Hospital  for  the   Ruptured  and  Crippled ;    and 

255  were  in  children  below  14  years 
of  age.  This  scarcity  of  cases  in  older 
persons  is  noted  in  all  hospital  clinics, 
but  it  is  not  altogether  a  trustworthy 
observation  upon  which  to  depend, 
because  the  class  of  adults  who  would 
be  likely  to  come  to  such  clinics  would 
attach  but  little  importance  to  a  de- 
formity which  practically  caused  them 
no  inconvenience. 

Whitman-  attacked  the  same  ques- 
tion from  a  slightly  different  stand- 
point by  counting  the  proportion  of 
persons  with  knock-knee  among  adult 
males,  taken  consecutively  as  he  met 
them  in  the  streets  of  Boston.  In 
2,000  adult  males  be  observed  32  cases 
of  knock-knee,  and  although  it  is  im- 
possible to  state  even  approximately 
the  proportion  of  knock-kneed  chil- 
dren, he  calls  attention  to  the  fact 
that  it  is  not  likely  to  be  larger  than 
this.  From  his  observations,  therefore,  he  would  conclude  that 
there  was  not  a  very  great  tendency  in  children  to  outgrow  this 
deformity.  Noble  Smith,  several  years  ago,  reached  practically  the 
same  conclusion  making  observation  upon  adults  among  the  Eng- 
lish artisan  class,  where  of  course  rickets  is  vastly  more  common 
than  here.  Of  482  individuals  noticed,  the  legs  were  straight  in  160 
and  crooked  in  322.  As  Mr.  Smith  observes,  "we  have  no  record 
to  show  the  number  of  children  who  suffer  from  these  deformities 
in  comparison  with  those  who  do  not;  but  it  can  hardly  be  a  much 
larger  proportion  than  two  to  one." 

'  Gibney:   N.  Y.  Med.  Journ.,  Nov.  29th,  1884. 
2  N.  Y.  Med.  Record,  July  30th,  1887. 


Fig.  627. — Case  of  Knock-knee,  Showing 
also  the  Tracings  of  the  Legs  at  an  Interval 
of  Four  Years  with  no  Treatment. 


KNOCK-KNl'lE  AND   HOW  LEGS.  655 

In  general  one  may  say  with  regard  to  the  prospect  of  spontane- 
ous recovery  in  tiiis  deformity  that  if  existing  tf)  a  marked  degree 
in  a  child  of  some  si/.e  and  weight,  it  is  very  unlikely,  and  far  less 
favorable  than  in  the  case  of  bow  legs  of  a  similar  grade  of  severity. 

Mr.  Rushton  Parker'  believes  that  the  tendency  of  slight  knock- 
knee  is  very  strong  toward  recovery  if  at  once  the  body  weight 
is  taken  off  the  affected  joint,  and,  as  the  mildest  form  of  treat- 
ment, he  would  not  allow  the  child  to  walk,  and  this  he  would  ex- 
pect to  effect  a  cure  in  beginning  cases.  It  may  bfe  remarked  that 
no  treatment  is  harder  to  carry  out  practically  than  this. 

The  static  variety  of  knock-knee  occurring  in  adolescents  rarely 
reaches  a  severe  grade  nor  as  a  rule  is  it  progressive  to  any  extent, 
so  that  the  mildest  measures  are  generally  sufficient  to  restrain  its 
progress.  Often  it  is  not  possible  in  this  way  to  improve  it,  nor  is 
it  worth  while  to  resort  to  mechanical  measures,  but  rubbing,  gym- 
nastics, and  an  avoidance  of  the  standing  position  are  sufficient. 

When  the  expectant  method  is  chosen  in  rhachitic  knock-knee, 
the  child  should  at  once  be  put  upon  the  constitutional  treatment 
for  rickets.  If  the  knock-knee  is  merely  the  outcome  of  a  feeble 
general  condition,  the  patient  should  be  most  carefully  looked  after 
in  the  matter  of  hygiene,  and  tonic  treatment  and  gymnastics 
should  be  given,  the  aim  of  which  should  be  to  strengthen  the  leg 
muscles.  As  much  as  possible  the  patient  should  be  kept  off  of 
the  feet,  and  a  change  to  country  air  is  capable  of  effecting  great 
local  improvement  in  feeble  children.  Gibney  spoke  of  several 
instances  where  he  had  known  marked  bony  changes  to  be  over- 
come by  a  season  in  the  country. 

The  legs  should  be  rubbed  and  manipulated  each  night.  The 
rubbing  should  be  the  same  as  that  described  under  infantile  par- 
alysis and  the  manipulation,  in  cases  of  knock-knee,  should  be  di- 
rected to  the  gentle  correction  of  the  deformity  by  repeated  mild 
manual  pressure.  The  figure  shows  the  position  of  the  hands,  and 
with  one  hand  the  manipulator  presses  the  knee  outward  while 
with  the  other  he  presses  the  lower  end  of  the  tibia  inward.  Even 
with  a  very  slight  degree  of  force  a  certain  yielding  can  be  felt  in 
the  direction  of  improvement  and  then  the  pressure  should  be  re- 
laxed and  the  limb  allowed  to  resume  its  first  position.  This  man- 
ipulation should  be  repeated  many  times,  continuing  each  pressure 
only  a  few  seconds.  Nor  should  it  ever  be  done  forcibly  or  long 
enough  to  make  the  child  cry. 

This  manipulation  faithfully  carried  out  is  an  important  adjuvant, 
not  only  of  expectant  but  of  mechanical  treatment. 

Expectant  treatment,  however,  is  most  limited  in  its  scope.     It 

'  Liverpool  Med.-Chir.  Journ.,  Jan.,  1SS7,  iig. 


656 


ORTHOPEDIC  SURGERY. 


is  only  to  be  considered  in  the  mildest  cases  in  young  children,  and 
even  here  to  be  adopted  with  very  great  reserve.  But  little  harm 
is  done  in  applying  splints  to  a  child  who  might  possibly  improve 
without  them,  but  a  great  deal  of  harm  may  be  done  by  allowing 
the  deformity  to  increase  because  splints  were  not  applied.  In  no 
case  should  expectant  treatment  be  considered  where  the  child  is 
not  under  sufificiently  close  observation  to  be  seen  every  few  weeks 
and  have  tracings  taken  to  determine  whether  the  deformity  is 
improving  or  stationary. 

II.  Mechanical  Treatment. — Treatment  by  apparatus  aims  at  the 
gradual  correction  of  the  deformity,  at  times  by  taking  the  weight 
off  the  limbs,  but  more  commonly  by  making  counter-pressure 
against  the  internal  condyle  to  prevent  the  further  giving  way  of 


Fig.  628. — Manipulation  in  the  Treatment  of  Knocli-knee. 


the  knee  and  to  pull  it  outward  to  a  fixed  point  furnished  by  an 
outside  upright.  Upon  this  principle  all  modern  apparatus  is  con- 
structed. 

The  method  of  Hueter'  forms  a  sort  of  transition  from  the  ex- 
pectant to  the  mechanical  method.  He  advocated  in  mild  cases  of 
knock-knee,  flexing  the  knee  and  retaining  it  in  the  flexed  position 
by  the  application  of  a  plaster-of-Paris  bandage.  It  has  been 
seen  that  the  deformity  disappears  on  flexion  and  he  claimed  that 
continued  flexion,  by  preventing  hyperextension  of  the  knee,  al- 
lowed the  condyles  to  grow  again  into  their  normal  relation  to 
each  other,  so  that  when,  after  a  considerable  period,  the  knee  was 
extended,  the  deformity  had  disappeared.  In  this  way  he  asserted 
that  he  had  cured  not  only  mild  but  severe  cases  of  the  deformity. 
The  method  has  only  to  be  mentioned  to  be  condemned.     It  was 

'  Hueter:    Archiv  fiir  Klin.  Chir. ,  ix.,  g6i. 


KNOCK-KNI'J':  AND    HOW  IJ'.GS.  657 

tried  in  Germany  h)y  Mickulicz,  Koiiij^s  and  Waitz,  who  failed  to  ^ct 
good  results  by  its  use,  and  its  manifest  inconveniences  in  crippling 
the  child  for  so  long  a  time  mu'st  needs  stand  in  its  way  even  if  it 
were  universally  admitted  to  be  an  efficient  method. 

Another  method  which  partakes  largely  of  the  expectant  plan  is 
one  spoken  of  by  Mr.  Rushton  Parker,  and  which  the  writers  have 
tried  experimentally.  It  is  based  upon  the  interdependence  of  flat- 
foot  and  knock-knee,  which  suggests  the  treatment  of  knock-knee 
by  correcting  the  flat-foot,  either  by  the  device  of  Mr.  Thomas, 
who  raises  the  inner  side  of  the  foot  by  sloping  off  the  sole  of  the 
boot  toward  the  outer  side ;  or  by  some  of  the  various  forms  of 
iron  sole  plate  which  elevate  the  arch  of  the  foot,  and  so  induce  a 
more  correct  position  in  standing.  This  plan  is  also  advocated  by 
Owen.  Practically  it  is  possible  to  improve  the  condition  of  flat- 
foot  very  much  while  the  knock-knee  becomes  worse  or  remains 
stationary.  The  plan  of  treatment  is  not  one  which  can  be  relied 
upon. 

Mechanical  treatment  proper  is  capable  of  the  most  brilliant  re- 
sults in  suitable  cases,  but  there  comes  a  stage  when  it  is  powerless 
to  accomplish  much  and  operative  measures  must  be  adopted.  To 
decide  when  the  applicability  of  mechanical  treatment  ends  is  a 
difficult  matter  of  judgment.  In  general  the  field  of  mechanical 
treatment  is  limited  to  rhachitic  children  whose  bones  are  still 
somewhat  soft. 

In  children  where  the  change  known  as  eburnation  has  succeeded 
rickets,  the  bones  are  so  hard  and  unyielding  that  it  is  almost  hope- 
less, by  means  of  such  mild  traction  as  can  be  exerted,  to  pull  the 
knee  back  into  place.  Whether  or  not  this  eburnation  is  present  is 
often  a  dif^cult  matter  to  decide;  A.  S.  Roberts'  bores  down  upon 
such  bones  with  a  drill  and  finds  out  in  that  way.  If  the  bones 
are  eburnated  the  drill  enters  with  much  difficulty,  if  the  bones 
are  still  soft  it  goes  into  them  with  scarcely  more  resistance  than 
in  passing  through  muscle.  But  this  is  rather  a  harsh  means  of 
diagnosis,  and  it  is  better  to  depend  upon  the  age  of  the  child  and 
the  resistance  offered  by  the  bones  on  manual  pressure.  In  gen- 
eral terms,  it  is  not  probable  that  mechanical  treatment  will  be  of 
use  after  the  age  of  three  or  four  years  has  been  reached ;  nor  is 
osteotomy  or  osteoclasis  likely  to  be  considered  before  that  time, 
at  the  earliest. 

Mechanical  treatment,  it  has  been  said,  is  of  tAvo  kinds.  The  old- 
fashioned  method  was  to  confine  the  child  to  the  bed  or  to  some 
retentive  apparatus,  while  modern  treatment  allows  and  encourages 
locomotion.     The  principle  of  both  is,  as  w^e  have  seen,  to  make 

'  A.  S.  Roberts:  Phil.  Med.  News,  Feb.  4th,  1888. 
42 


658 


ORTHOPEDIC  SURGERY. 


outward  pressure  against  the  knees  and  inward  pressure  against 
the  feet.  The  aim  of  this  is  to  cause  atrophy  of  the  internal  con- 
dyle, with  overgrowth  of  the  external  one,  so  that  the  plane  of  the 
knee-joint  may  once  more  become  normal.  Simply  to  stretch  the 
external  lateral  ligaments,  without  altering  the  relation  of  the  con- 
dyles, would  result  in  a  laterally  movable  joint. 

Former  orthopedic  methods  are  exemplified  by  methods  of  re- 
cumbency, and  while  some  writers  still  adhere  to  the  treatment  of 
knock-knee  by  recumbency,  that  method  has   practically  become 

obsolete.  The  felt  cushion  is  applied 
between  the  knees  while  the  patient 
lies  flat,  and  the  feet  are  bandaged 
together. 

In  the  ambulatory  treatment  of  the 
affection,  the  number  of  splints  in  use 
is  bewildering,  and  it  matters  little 
which  form  one  adopts.  As  a  rule, 
traction  from  a  rigid  outside  rod  is  bet- 
_  I        /T\  ^      \  -^  ter  than  from   an   elastic  one,  because 

it  is  more  definite,  and  more  easily  con- 
trolled. 

Whatever  apparatus  is  used  should 
be  capable  of  holding  the  leg  extended, 


Fig.  629. — Outside  Splints  for  Knock-knee. 


Fig.  630. — P'elt  Cushion  of  Heine. 


remembering  always  the  tendency  which  such  legs  have  to  flex, 
and  rotation  of  the  limb  inside  of  the  apparatus  should  be  made 
impossible. 

Perhaps  as  useful  a  form  as  any  is  the  one  figured,  which  has 
been  in  use  for  some  years  at  the  Children's  Hospital,  and  which 
has  proved  itself  efficient  in  practical  use.  It  is  a  light  steel  rod 
attached  below  to  a  steel  sole  plate  and  jointed  at  the  ankle.  It 
runs  up  the  outside  of  the  leg  as  far  as  the  trochanter  and  then 
the  rod  is  bent  backward  and  upward,  as  the  figure  shows,  to  lie 
against  the  upper  part  of  the  buttock  and  to  serve  as  an  arm  by 
which  the  leg  can  be  everted  or  inverted  if  the  child  toes  in  or  out 
m  walking.     Merely  to  carry  the  shaft  up  to  the  trochanter  and 


knock-kn]':e  and  now  l/lGS. 


659 


finish  in  ;i  plate  applied  to  tiie  outside  of  tlu;  tlii^di  is  practically  a 
much  less  efficient  ap[)aratus,  because  the  le^  will  rotate  inside  of 
the  splint  under  these  conditions,  and  flexion  of  the  thiyh  will  nr^t 
be  so  easily  controlled,  and  for  this  reason  the  posterior  arms  should 
be  carried  up  and  back  even  when  there  is  no  eversion  or  inver- 
sion of  the  feet.  The  knee  is  drawn  upon  by  a  square  leather  pari, 
pulling  from  the  shaft  opposite  the  knee.  The  upper  ends  of  the 
apparatus  should  be  buckled  posteriorly  together  by  two  straps, 
one  connecting  the  tips  of  the  posterior  arms,  and  sometimes  an- 
other may  be  needed  running  across  the  lower  abdomen,  connect- 
ing the  shafts;    by  lengthening  and   shortening  these   straps   it   is 


Fig.  631. 


Fig.  632. — Hester's  Knock-     Fig.  633. — Tuppert's  Splint 
knee  Apparatus.  for  Knock-knee. 


evident  that  any  desired  degree  of  inversion  or  eversion  of  the  feet 
may  be  produced.  Often  the  posterior  strap  alone  is  all  that  is 
needed. 

A  very  much  cheaper  and  simpler  apparatus  is  mentioned  by 
Noble  Smith,  consisting  of  two  straight  outside  wooden  splints, 
attached  together  at  the  top  by  a  band  to  encircle  the  posterior 
half  of  the  pelvis,  and  belov/  strapped  to  the  ankles  by  a  broad 
piece  of  webbing.  They  run  down  the  outside  of  the  legs  and  the 
knees  are  pulled  out  to  them. 

There  is  no  advantage  in  carrying  the  outside  uprights  to  a  rigid 
waist  band  as  is  done  sometimes ;  it  necesitates  an  expensive  ap- 
paratus with  joints  at  the  hips  and  presents  no  advantage  over  the 
simpler  kind  just  described. 


66o 


ORTHOPEDIC  SURGERY. 


Joints  at  the  knee  are  not  advisable,  for  not  only  is  it  impossi- 
ble to  obtain  so  firm  a  hold  on  the  joint  where  it  is  continually 
bending,  but  with  each  degree  of  flexion  the  deformity  diminishes 
and  an  apparatus  allowing  motion  at  the  knee  loses  much  in  effi- 
ciency and  accuracy. 

Other  forms  of  this  splint  in  use,  which  are  obviously  not  so  effi- 
cient or  so  sightly  as  the  simple  ones  described,  are  those  of  Hester 
and  Tuppert. 

Shaffer  brings  in  a  modification  in  the  working  of  the  apparatus, 
by  having  an  adjustable  splint,  which  can  be  bent  to  any  lateral 
angle  by  turning  the  key  which  works  a  traction  rod,  as  seen  in 
the  figure.  The  splint  is  applied  to  the  limb  in  its  deformed  posi- 
tion, and  buckled  tightly  in  place,  and  then,  by  turning  the  key, 


Fig.  634. — Shaffer's  Splint  for 
Knock-knee. 


Fig.  635. — Heine's  Plaster-of  Paris  Splint  for  Knock-knee 
with  the  Clamps  by  which  the  Outside  Rod  is  Atttached. 


the  splint,  and  with  it  the  limb,  is  straightened.  The  splint  is  an 
efficient  but  expensive  one. 

Heine  has  proposed  a  cheap  plaster-of-Paris  splint,  the  construc- 
tion and  use  of  which  is  evident  from  the  figure,  and  German 
writers  speak  well  of  it.  The  precaution  is  taken  of  cutting  out  an 
elliptical  piece  of  the  plaster  over  the  inner  side  of  the  knee,  where 
the  pressure  is  to  come.  To  attempt  to  correct  the  deformity  by 
the  pressure  of  a  plaster  bandage  alone,  would  be  almost  sure  to 
cause  sloughing. 

The  .best  example  of  the  braces  which  would  substitute  elastic 
for  rigid  traction  is  the  one  which  Roberts  uses  and  describes,  and 
it  can  be  seen  in  the  figure. 

Other  forms  of  braces  exerting  elastic  traction  are  shown  in  the 
figures  of  the  plaster-of-Paris  bandages  of  Mickulicz  and  Vogt.  In 
the  former  bandage  one  includes  in  front  of  and  behind  the  joint  ar- 


KNOCK-KNIil'.  AN  J)    HOW  JJ'JiS. 


CGi 


ticulated  pieces  of  iron,  and  at  the  inner  side  two  hooks,  soldered  on 
to  tin  plates,  one  above  and  one  below  the  knee.  The  plaster 
bandage  is  applied  in  two  halves,  and  these  are  all  incorporated. 
When  it  is  dry,  elastic  traction  is  maintained  by  a  stout  rubber 
band,  connecting  the  two  hooks.  Mickulicz  says  that  in  this  way 
a  moderately  bad  case  of  knock-knee  may  be  ciircfl  in  a  few  weeks. 
The  bandage  of  Vogt  is  a  slight  modification  of  the  same  principle. 
Beyond  the  age  of  three  or  four  years  it  is  not  likely  that  one  will 
find  any  elasticity  to  the  bones  or  much  if  any  yielding  to  lateral 
pressure  at  the  knee,  and  it  must  be  remembered  that  after  the  age 
of  three  years  the  results  of  mechanical  treatment  are  less  satisfac- 
tory than  before  that  time  and  that  in  no  case  after  that  time  is  it 


mi. 


Fig.  636. — Roberts'  Brace  for  the  Correction     Fig.  637. — Mickulicz's  Plaster  Band- 
of  Knock-knee  by  Elastic  Traction.  age  with  Elastic  Traction. 


Fig.  638. — Vogt's 
Bandage. 


advisable  to  apply  apparatus,  unless  the  bones  yield  to  manipula- 
tion. In  the  older  methods  of  treatment,  long  continued,  with  re- 
cumbency in  bed,  successful  cures  have  been  reported  in  patients 
much  older  than  would  be  subjected  to  mechanical  treatment  in 
the  practice  of  modern  orthopedic  surgeons,  who,  since  the  intro- 
duction of  osteotomy,  are  more  Inclined  to  resort  to  operative  pro- 
cedures than  to  subject  their  patients  to  an  extended  treatment 
requiring  prolonged  confinement.  Entirely  satisfactory  results  in 
adolescents  are  reported  by  Little.  The  writers  can  record  a  suc- 
cessful case  by  ambulatory  mechanical  treatm.ent  in  a  child  of  six, 
a  severe  case  of  double  knock-knee  where  over  a  year's  treatment 
w^as  necessary. 

The  objections  made  to  the  mechanical  treatment  of  genu  val- 
gum are  that  the  treatment   is  tedious  and  that  it  is  often  difificult 


662 


ORTHOPEDIC  SURGERY. 


to  secure  the  cooperation  of  the  parents  in  the  proper  use  of 
the  apparatus;  that  the  correction  of  the  deformity  is  made  by 
stretching  the  hgaments  on  the  outer  side  of  the  joint  and  that  the 


Fig.  639.  Fig.  640. 

Fig.";.  639,  640. — Knock-knee  Cured  in  Three  Years  by  the  Use  of  the  Simple  Outside  Upright; 
Being  a  Good  Average  Result. 

deformity  cannot  be  properly  compensated  for  until  the  external 
condyles  have  grown  to  their  proper  length,  which  is  a  process 
often  requiring  much  time. 


Fig.  641.  Fig.  642. 

Figs.  641,  642. — Tracings  of  Case  of  Knock-knee  showing  Improvement  Under  Mechanical  Treatment 

in  One  and  One-half  Years. 

III.   Operative  Treatment. — The  modern  operative  treatment  of 
knock-knee  is  comprised  for  the  most  part  under  the  simple  opera- 


KNOCh'-h'N /•:/<:  AND   now  LECiS.  663 

tions  of  osteotomy  or  osteoclasis.  There  are  two  operative  pro- 
cedures which  are  still  sometimes  resorted  to  and  which  deserve 
mention.  These  are:  {a)  division  of  the  ligaments  or  tendons  at 
the  outside  of  the  knee;  (/-')  rcdressement  forc6  (Delore's  methodj, 
or  sudden  reduction  of  the  deformity  by  means  of  manual  force,  a 
proceeding  which  should  hardly  be  considered  under  the  head  of 
osteoclasis.  The  others  are:  (c)  osteotomy;  (d)  osteoclasis;  ie) 
excision  of  the  joint. 

{a)  Tenotomy  of  the  biceps  and  division  of  the  fascia  is  an 
operation  which  has  no  place  in  the  surgery  of  to-day,  for  in  cases 
which  could  be  remedied  by  this  proceeding  it  would  be  much  better 
to  use  apparatus.  Sometimes  in  cases  of  knock-knee,  <\v\(^  to  infan- 
tile paralysis  or  tumor  albus,  it  may  be  desirable  to  cut  the  biceps 
tendon  as  an  adjunct  to  some  straightening  operation. 

{b)  The  forcible  reduction  of  the  deformity  by  manual  pressure  as 
proposed  by  Delore  has  never  met  with  very  wide  acceptance  in 
America.  Barbier'  demonstrated  with  some  care  the  anatomical 
changes  likely  to  be  found  after  its  performance.  By  experiments 
upon  the  cadaver  he  produced,  in  doing  this  operation,  injuries  to 
the  epiphyseal  lines  of  the  fem_ur  and  tibia,  ruptures  of  the  perios- 
teum, and  often  laceration  of  the  external  lateral  ligament.  Delore 
admits  that  the  reduction  is  often  at  the  expense  of  the  external 
lateral  ligaments,  and  in  a  case  which  he  had  an  opportunity  to 
examine  post-morten  twenty-one  days  after  the  operation,  the  ex- 
ternal half  of  the  joint  surfaces  were  not  in  contact  with  each 
other.= 

Santi,  experimenting  upon  the  cadaver,  found  that  in  twelve 
operations  the  external  lateral  ligament  was  ruptured  nine  times; 
twice  the  external  condyle  was  separated,  and  once  there  was  a 
fracture  into  the  joint. 

Experiments  by  Samuel  and  others  upon  the  dead  bodies  of 
children  from  two  to  fifteen  years  old  have  shown  that  separation 
of  the  epiphyses  is  more  likely  to  happen  than  rupture  of  the 
lateral  ligaments ;  for  in  ten  cases  there  was  separation  of  the 
epiphysis  of  the  femur  or  the  tibia,  or  of  both,  while  in  only  three 
cases  was  the  external  lateral  ligament  torn.  It  would  seem,  for 
these  reasons,  that  the  operation  was  one  attended  by  such  unde- 
sirable anatomical  changes  that  it  was  not  a  justifiable  procedure. 

The  clinical  evidence  is  more  favorable  to  the  proceeding  if  we  may 
believe  the  testimony  of  its  advocates.  Out  of  300  cases  operated 
on  in  this  way  by  French  surgeons  (including  Delore's  200  opera- 
tions), only  2  deaths  occurred ;    one  from  scarlatina  and  one  from 

^  "Etude  sur  le  Genu  Valg.":    These  de  Paris,  1874. 
^  Delore:    Gaz.  des  Hop.,  1874. 


664  ORTHOPEDIC  SURGERY. 

pyaemia.  Ormsby  has  operated  in  this  way  many  times  for  knock- 
knee,  as  well  as  for  bow  legs,  and  in  hundreds  of  cases '  has  never 
seen  a  complication.  At  the  International  Medical  Congress  in 
i88i,  Fochier  was  the  only  one  to  raise  his  voice  in  defence  of  the 
operation. 

The  bad  results  of  the  operation  as  reported  by  its  critics,  are  in 
some  cases  immediate  effusion  into  the  joint  and  arthritis,  severe 
periostitis  resulting  from  injuries  to  the  periosteum,  and  at  times 
necrosis,  superficial  or  deep.  The  remote  bad  result  of  the  opera- 
tion is  apt  to  be  a  weak  and  lax  state  of  the  joint,  which  often  re- 
quires mechanical  support  for  a  long  period,  and  sometimes  defect- 
ive growth  of  the  bone  due  to  the  epiphyseal  injury  is  a  cause  of 
disability. 

Delore  performs  the  operation  as  follows:  the  patient  lies  on  the 
back,  and  the  deformed  leg  is  rotated  outward  touching  the  table 
at  the  trochanter  and  malleolus.  The  surgeon  then  bears  his 
weight  upon  the  inner  surface  of  the  knee  by  a  succession  of  jerks 
and  pressures  on  the  leg,  until  it  yields  and  can  be  rectified.  Mic- 
kulicz,  however,  performs  the  operation  by  one  sudden  jerk.  By 
the  former  method  the  operation  takes  several  minutes,  but  finally, 
cracking  sounds  are  heard  and  the  leg  can  be  straightened. 

Tillaux  performs  the  operation  by  using  the  internal  condyle 
as  a  fulcrum,  and  while  the  thigh  is  steadied  by  an  assistant,  he 
bends  the  knee  laterally  inward  over  the  edge  of  a  table. 

The  experiments  of  Paoli  ^  show  a  safer  way  to  perform  this  ope- 
ration. In  general  he  found  injury  to  the  lateral  ligaments  when 
the  operation  was  performed  in  the  usual  way ;  especially  in  older 
children.  He  discovered  that  this  could  be  avoided  by  first  frac- 
turing the  limb  by  hyperextension  and  correcting  the  deformity 
afterward  by  adduction.  The  knee  is  hyperextended  over  the 
edge  of  a  table  while  the  child  lies  on  his  face;  and  then,  after  the 
knee  has  snapped,  the  patient  is  turned  on  the  side  and  adduction 
performed. 

Delore  would  operate  by  his  method  upon  patients  up  to  the 
age  of  eighteen.  But  the  operation  is  so  manifestly  rough  and 
unsurgical  that  few  would  be  inclined  to  resort  to  it  at  the  present 
time. 

(<f)  Osteotomy. — The  history  of  this  operation  is  not  a  question  of 
any  practical  value.  Osteotomy  was  performed  in  a  rough  way  in 
cases  of  badly  united  fractures,  even  in  the  tim.e  of  Hippocrates 
and  his  successors.  Rhea  Barton  performed  osteotomy  some  sixty 
years  ago  with  an  open  wound,  using  the  saw  and  forceps.  Sub- 
cutaneous osteotomy  was  first  suggested   by  Malgaigne  and  per- 

^  Ormsby:  Dublin  Journal,  1885,  p.  483.  ^  Paoli  :  Cent.  f.  Chir.,  18S6,  2,  27. 


h'NOCK-KN /■:/•:   AND    /lOlV  /JCGS.  f/^-^ 

formed  by  Lan^cnbcck  .'iiul  Meyer.  The  latter  .sur<^ef;n  performed 
the  first  osteotomy  for  <^enu  v<dgum.  The  modern  prominence  of 
osteotomy  is  due  to  the  Labors  of  Ikainard,  Meyer,  Annandale, 
Volkmann,  Ogston,  and  lastly  and  most  preeminently,  of  Maccwen 
of  Glasgow. 

The  operation  consists  in  tlie  subcutaneous  division  of  part  of 
the  bone  by  the  chisel  or  saw,  and  the  c(jmpleti(m  of  the  procedure 
by  fracture  of  the  partly  divided  bone. 

The  operations  all  have  much  the  same  aim  and  differ  only  in 
detail;  their  object  is  either  one  of  these  three  things: 

(i)  Separation  of  the  internal  condyle  and  its  displacement  up- 
ward. 

(2)  Section  of  the  upper  end  of  the  tibia  and  perhaps  the  fibula. 

(3)  Section  of  the  femur  above  the  condyles. 

The  operation  of  osteotomy  performed  with  antiseptic  precau- 
tions is  not  one  which  is  attended  with  any  especial  risk.  Mac- 
ewen,  in  1884,  had  done  osteotomy  for  genu  valgum  820  times,' 
with  5  deaths;  and  in  no  case  was  death  to  be  considered  as  directly 
traceable  to  the  operation;  the  patients  dying  of  pneumonia,  mea- 
sles, etc.  Collecting  the  cases  of  other  British  surgeons  he  had, 
with  his  own  820,  1,384  cases  of  knock-knee  operated  upon  by  his 
method,  with  3  deaths  due  to  operation;  two  of  which  were  caused 
by  septicaemia  and  the  cause  of  the  third  is  not  stated. 

Accidents  from  carefully  performed  osteotomy  have,  however, 
been  reported.  Howard  Marsh''  wounded  the  anastomotica  magna 
artery  in  performing  Macewen's  operation,  and  a  few  days  later 
was  obliged  to  cut  down  on  it  and  tie  it.  McGill^  reported  a  case 
where  the  popliteal  artery  was  divided  and  had  to  be  ligatured. 
Gibney*  reports  a  case,  of  severe  hemorrhage  from  the  bone  and 
speaks  of  it  as  the  only  severe  hemorrhage  that  he  has  ever  seen 
from  the  operation.  He  also  mentions  another  case  of  Avhich  he 
knew,  where  the  anastomotica  artery  was  wounded.  Fatal  bleed- 
ing has  resulted  from  the  operation, =  and  Langton  *  reports  death 
after  amputation  of  the  thigh  on  account  of  gangrene,  consequent 
upon  ligation  of  the  popliteal  artery  v^dlich  had  been  punctured  b}- 
a  sharp  spicule  of  bone  projecting  from  the  lower  fragment. 

The  external  peroneal  nerve  has  been  divided,  and  doubtless  a 
large  number  of  accidents  which  have  occurred  have  never  been 
reported;  but  the  universal  testimony  with  regard  to  the  operation, 

'  Macewen  :    Lancet,  Sept.  27th,  1S84. 

'  Brit.  Med.  Joiirn.,  1S84,  i.,  665  ;  Lancet,  May  17th,  1SS4,  p.  Sgi. 

3  McGill  :    Lancet,  May  17th,  1884. 

4  N.  V.  Med.  Journal,  Dec.  6th,  1S84. 

5  Phila.  Med.  News,  Nov.  ist,  18S4. 
^Lancet,  Mar.  29tli,  1884. 


666 


OR  THOPEDIC  S  UR  GER  V. 


is  that  in  the  main  it  is  safe,  and  very  unlikely  to  be  attended  by 
unfortunate  consequences.' 

Davy  =  analyzed  64  operations  for  knock-knee  by  Ogston's  method 
without  any  mishap ;  but  hemorrhage  is  more  frequent  after 
Ogston's  than  after  Macewen's  operation.  In  525  operations  by 
Ogston's  method  there  were  13  hemorrhages  of  considerable  sever- 
ity, while  in  580  osteotomies  done  by  Macewen's  method,  there 
were  only  2  cases  of  such  bleeding. 

Macewen  says  that  hemorrhage  which  occurs  in  the  perform- 
ance of  the  operation  as  described  by  him,  is  due  to  one  of  these 
mistakes:  the  use  of  too  broad  an  instrument;  by  not  cutting  the 
posterior  part  of  the  bone  with  the  chisel  pointed  forward  and 
outward,  but  by  allowing  the  chisel  to  point  backward;  by  holding 

the  osteotome   loosely  and  letting  it  slip 
during  the  cutting. 

Division  of  the  bone  was  formerly  ac- 
complished by  first  boring  holes  with  a 
gimlet  in  the  line  of  the  intended  sepa- 
ration; then  the  same  end  was  accom- 
plished by  the  use  of  the  trephine,  chain 
saw,  or  a  narrow  straight-bladed  saw ;  but 
finally  the  chisel  and  mallet  have  come 
to  supersede  all  other  instruments  except 
the  small  saw. 

There  are  two  forms  of  chisel  in  use,  the 
Billroth  osteotome  and  the  simple  chisel 
or  osteotome  already  described  in  Chap- 
ter VL,  which  should  be  m'arked  on  one 
side  of  the  blade  with  lines  one-quarter  of  an  inch  apart  to  show 
how  deeply  the  edge  has  penetrated.  It  is  very  convenient  to  have 
two  breadths  of  chisel,  one  three-eighths  of  an  inch  wide,  the  other 
five-eighths  or  three-quarters  of  an  inch  wide.  They  should  be 
about  six  inches  long;  but  if  only  one  width  is  practicable  it  should 
be  half  an  inch  wide. 

Longitudinal  osteotomy  ^  is  a  proceeding  advocated  by  Jeannel, 
of  Toulouse,  who  has  practised  it  with  satisfactory  results.  In  this 
way  he  obtains  lengthening  of  the  bones  as  well  as  their  lateral 
correction.  The  method  is  also  supported  by  the  authority  of 
Oilier.     The  writers  have  had  no  experience  with  it. 

It  is  not  worth  while  to  describe  fully  the  operations  for  supra- 
condyloid  osteotomy,  except  that  of  Macewen.     Mac  Cormac  ad- 

'  La  Semaine  Med.,  April  nth.  i88g. 

^  Brit.  Med.  Journ. ,  June  30th,  1888,  p.  1,377. 

3  Lancet,  April  2rst,  i88g. 


Fig.  643. — Billroth's  Osteotome. 


KNOCK-KNEK  AN  J)   JiOW  LEGS.  667 

vocated  '  section  from  the  outside  instead  of  the  inside,  and  Keeves"" 
advocates  division  of  the  femur  just  below  its  middle,  while  Hahn 
would  cut  above  the  condyles  on  both  the  inside  and  the  outside 
of  the  leg.  The  operation  of  Macewen  has  superseded,  not  only- 
all  supra-condyloid  operations,  but  all  others  for  the  correction  of 
knock-knee, 

Macewen's  operation  is  performed  as  follows:  the  patient's  leg 
is  rendered  aseptic ;  the  patient  lies  on  his  side  with  the  leg  ex- 
tended, the  outer  side  of  the  knee  resting  on  a  sand-bag.  The  skin 
and  underlying  tissues  are  then  divided  with  a  knife  over  the 
point  of  division  of  the  bone,  or,  what  is  more  simple,  the  chisel  is 
driven  through  the  sound  skin  into  the  bone  without  any  incision. 
This  diminishes  the  bleeding  and  simplifies  the  operation.  The 
use  of  an  Esmarch  bandage  is  unnecessary. 

The  point  selected  for  operation  is  at  the  inner  side  of  the  thigh, 
half  an  inch  above  the  adductor  tubercle  of  the  femur.  The  osteo- 
tome is  driven  into  the  bone  with  the  blade  at  right  angles  to  the 
long  axis  of  the  femur,  and  by  successive  blows  with  the  mallet  the 
operator  cuts  nearly  through  the  whole  thickness  of  the  bone. 
The  osteotome  is  likely  to  become  wedged  very  firmly  unless  the 
precaution  is  taken  to  move  the  handle  of  the  chisel  laterally  after 
each  blow.  In  thi's  way  alone  can  one  cut  from  the  front  to  the 
back  of  the  bone,  for  driving  the  chisel  straight  through  in 
one  line  accomplishes  nothing.  When  the  chisel  has  disappeared 
to  a  depth  indicating  that  three-quarters  of  the  bone  has  been 
divided,  it  should  be  withdrawn  and  an  attempt  made  to  fracture 
the  thigh  by  gentle  bending.  If  this  cannot  be  done,  the  osteo- 
tome should  cut  further,  for  the  common  cause  of  this  is  a  failure 
to  divide  the  anterior  and  posterior  borders  of  the  femur. 

When  the  bone  has  broken,  manipulation  should  be  avoided  ex- 
cept to  put  the  leg  in  a  corrected  position,  and  after  an  antiseptic 
dressing  has  been  applied  to  put  on  a  plaster-of-Paris  bandage  and 
hold  the  leg  in  a  corrected  position  until  the  plaster  is  hard. 
Slight  pain,  if  any,  follows  the  operation  and  there  should  be  no 
fever.  No  change  of  dressing  is  needed ;  the  plaster  may  be  re- 
moved in  three  or  four  weeks,  and  in  six  weeks  the  patient  allowed 
to  stand  on  the  limbs. 

Hahn,  in  a  recent  very  complete  article  on  the  treatment  of  genu 
varum  and  valgum,  advocates  the  performance  of  osteotomy  on 
the  outer  as  well  as  on  the  inner  side  of  the  leg ;  in  this  wa}'  he 
thinks  that  he  obtains  greater  precision  in  the  location  of  the  frac- 
ture, than  in  chiselling  the  outer  side  of  the  femur  alone.^ 

'  "Antiseptic  Surgery,"  p.  189.  -  Brit.  Med.  Journ.,  Dec.  20th,  1881. 

3 Berliner  Klinik  f.  10.  April,  18S9. 


668 


ORTHOPEDIC  SURGERY. 


Fig.  644. — Diagram  of  the  Supra-Condyloid  Correc- 
tion of  Knock-knee,  a.  Before  operation:  /;,  the 
inner  section  of  the  bone;  c,  corrected  position;  </, 
corrected  position  after  section  of  the  bone  from  the 
outer  side. 


Brenner/  the  assistant  of  Dittel,  advocated  doing  the  operation 
as  in  Mac  Cormac's  method  from  the  outside.  He  uses  a  small 
chisel  and  makes  only  a  small  external  opening  into  the  bone, 
thereby  saving  the  periosteum,  but  this  presents  no  practical 
advantage. 

It  can  be  seen  from  the  diagram  that  the  corrected  position  of 

the  bone  is  equally  good  whether 
the  incision  is  made  on  the  outer 
or  the  inner  side  of  the  shaft. 

The  result  of  osteotomy  at  the 
point  of  division  of  the  bone 
was  shown  in  a  specimen  de- 
scribed by  Dr.  A.  T.  Cabot'  some 
years  ago.  He  had  performed 
a  Macewen  operation  and  the 
child  died  in  six  weeks  of  ty- 
phoid fever.  On  the  outer  side 
of  the  bone  the  line  of  the  shaft 
was  well  preserved ;  but  on  the 
inner  side  the  compact  wall  of  the  shaft  had  been  driven  down  into 
the  cancellated  tissue.  In  the  centre  the  lower  fragment  was  im- 
pacted into  the  upper,  which  locking,  of  course,  resulted  in  great 
firmness.  There  was  but  slight  callus  formation  and  only  a  thin 
layer  of  bone  under  the  periosteum  on  the  outer  side. 

The  advantages  of  Macewen's  operation  are  these :  It  is  easier 
to  perform  than  any  other  and  is  applicable  to  nearly  all  cases.  It 
is  so  far  removed  from  the  joint  that  one  avoids  injury  to  liga- 
ments and  synovial  membrane,  and  yet  the  line  of  section  is  near 
enough  to  the  point  of  abnormal  deviation  to  enable  the  deformity 
to  be  corrected  by  straightening  the  limb. 

The  chief  operations  upon  the  condyles  are  Ogston's,  Reeve's, 
and  Chiene's. 

In  the  performance  of  Ogston's  operation,  a  knife,  which  is  small 
and  sharp-pointed,  is  entered  about  two  inches  above  the  adductor 
tubercle  of  the  femur,  exactly  in  the  middle  of  the  inner  surface  of 
the  thigh,  and  is  then  passed  downward  and  outward  across  the 
front  of  the  condyles,  until  the  point  reaches  the  groove  between 
the  condyles,  which  is,  of  course,  within  the  cavity  of  the  joint. 
The  knife  is  then  withdrawn,  being  made  to  cut  down  to  the  bone 
on  its  way  out.  A  narrow-pointed  saw  is  then  introduced  through 
the  incision  and  passed  down  under  the  patella  until  its  point  can 
be  felt  in  the   intercondyloid  groove.     The  bone  is  sawed  nearly 


^  Medical  Press  and  Circular,  Feb.  29th,  1SS8. 

=  Boston  Med.  and  Surg.  Journal,  Feb.  i6th,  1883,  p.  154. 


KNOCK-KNEE  AN  J)   JiOW  LEGS. 


669 


through  with  short  quick  strokes  until  the  posterior  surface  of  the 
bone  is  nearly  reached.  The  saw  is  then  taken  out  and  the  limb 
straightened.  Except  for  very  severe  cases  this  operation  has  been 
superseded  by  Macewen's. 

Reeves  has  modified  this  operation  s(;  as  to  prevent  opening  the 
joint,  but  practically  his  modification  is  apt,  like  the  original  ope- 


Fig.  646. 


P'iG.  645. — Case  of  Knock-knee  Corrected  by 
Macewen's   Osteotomy.      (The    same   case   as 

shown  in  Fig.  617.) 


Fig.  647. 


Figs.  646,  647.— Diagram  of  the  Correction  of 
Knock-knee  by  Ogston's  Method,  Showing  Leg  and 
Diagram  of  Outline  of  Bones  of  Leg. 


ration,  to  cause  a  compound  fracture  into  the  joint.  He  operates, 
as  Ogston  did,  with  the  knee  flexed,  but  he  uses  a  chisel,  which  he 
inserts  in  a  much  smaller  incision,  simply  over  the  adductor  tuber- 
cle, and  drives  it  obliquely  into  the  condyle,  having  previously  esti- 
mated how  far  it  should  go  to  loosen  the  condyle.  After  cutting 
the    condyle    free    in    several    directions,   the    limb    can    be    easily 


670  ORTHOPEDIC  SURGERY. 

straightened.  Reeves'  operation  is  difficult  to  perform  and  is  gen- 
erally in  its  practical  result  the  same  as  Ogston's. 

The  operation  described  by  Mr,  Chiene  '  is  performed  as  follows: 
The  tubercle  of  the  internal  condyle  is  exposed  by  an  incision  two 
or  three  inches  long,  made  in  the  long  axis  of  the  limb,  and  the 
tendon  of  the  adductor  magnus  is  found  and  separated  from  the 
fibres  of  the  vastus  internus.  In  this  interspace  the  periosteum  is 
divided  with  a  crucial  incision  and  turned  aside,  exposing  the  bone, 
and  a  wedge  of  bone  is  removed,  the  long  axis  of  which  runs  down- 
ward and  outward  toward  the  notch  between  the  condyles. 

Schmitz^  performs  Ogston's  operation  through  a  larger  wound 
and  thinks  that  it  is  more  easily  and  effectually  done  in  that  way. 

Thiersch  3  raised  a  very  formidable  objection  to  Ogston's  opera- 
tion which  applies  equally  well  to  all  similar  procedures.  He  called 
attention  to  the  fact  that  the  interruption  of  the  epiphyseal  carti- 
lage might  easily  interfere  with  the  growth  of  that  part  of  the 
bone.  A  few  years  later.  Dr.  Poore,  of  New  York,  saw  a  case 
where  this  mishap  had  actually  occurred.  Two  years  after  an 
Ogston's  operation  the  left  knee  began  to  bend  outward  and  walk- 
ing became  difficult.** 

Sometimes  when  the  deformity  lies  chiefly  in  the  head  of  the 
tibia,  the  operation  of  osteotomy  might  be  performed  there  either 
alone  or  in  connection  with  femoral  osteotom.y.  The  removal  of 
a  wedge  of  bone  is  hardly  necessary  from  either  the  femur  or  tibia 
in  cases  of  knock-knee. 

By  nearly  all  writers  of  large  experience  who  have  no  operation 
of  their  own  to  advocate,  the  superiority  of  the  Macewen  operation 
is  admitted  ^  and  at  the  Boston  Children's  Hospital  the  Macewen 
operation  is  now  performed  to  the  exclusion  of  almost  every  other. 
The  only  fault  found  with  it  is  in  extreme  cases,  where  it  seems 
insufficient  to  correct  the  deformity;  here  the  Reeves  modification 
of  Ogston's  operation  is  the  most  satisfactory,  but  these  cases  are 
few. 

{d)  Osteoclasis. — The  forcible  fracture  of  bone  by  instrumental  or 
manual  means  in  knock-knee  is  decidedly  inferior  to  osteotomy, 
inasmuch  as  it  lacks  the  precision  of  that  method;  more  splinter- 
ing occurs,  and  rupture  of  the  external  ligaments  and  epiphyseal 
separation  are  apt  to  occur,  as  in  redressement  force.  These 
events  do  not  happen   in  osteotomy  and  they  are  serious  matters. 

'  Edin.  Med.  Journ.,  1879,  p,  881.      .  ^  Cent.  f.  Chir. ,  April,  1879. 

3  London  Med.  Rec,  June  15th,  1878. 

"*  Poore  :    "  Osteotomy  and  Osteoclasis,"  New  York,  1884,  p.  100. 
5  C.T.  Poore  and  others,  N.  Y.  Med.  Record,  Aug.  13th,  1881;  Little,  "  In-Knee," 
Longmans  and  Green,  London. 


KNOCK-KN /':/':  AND   HOW  JJ'ICS.  6/1 

It  is,  therefore,  better  to  limit  the  use  of  osteochisis  to  the  correc- 
trioif  of  bow  le^^s,  where  the  instrumental  oi'  manual  force  can  be 
applied  to  the  shaft  of  a  ionj^  bone,  rather  than  t'j  the  compara- 
tively delicate  structure  of  a  joint.  In  the  matter  of  risk  the  two 
operations  are  comparatively  on  a  level.  The  osteotomy  wound 
under  proper  precautions  does  not  add  in  the  least  to  the  gravity 
of  the  operation. 

Schede  advocates  manual  osteoclasis  in  the  treatment  (jf  j^enu 
valgum,  taking  care  not  to  rupture  the  external  ligaments  of  the 
knee-joint.  In  a  large  number  of  cases  treated  in  this  way  Schede 
has  had  no  mishaps.  In  older  children,  however,  he  performs 
Macewen's  osteotomy.' 

The  new  Collin  osteoclast,  however,  breaks  the  bones  with  such 
precision  that  osteoclasis  for  genu  valgum  seems  once  more  com- 
ing into  vogue,  especially  in  France.  Delens,  who  had  given  up 
osteoclasis  for  Macewen's  osteotomy,  has  returned  to  the  perform- 
ance of  osteoclasis  after  seeing  Collin's  new  osteoclast.  And  even 
Demons,  who  translated  Macewen's  book  into  French,  has  become 
recently  an  advocate  of  ostecolasis  for  genu  valgum.  Rollin  and 
Moliere  described  an  osteoclast  which  could  break  the  femur  within 
two  fingers'  breadths  of  the  joint,  without  affecting  the  articula- 
tion in  any  degree." 

{e)  Excision. — The  operation  of  excision  in  paralytic  knock-knee 
has  already  been  mentioned.  Its  advantage  lies  in  the  fact  that  it 
not  only  corrects,  but  stiffens  the  affected  joint,  which  is  a  great 
aid  to  those  patients  who  are  unable  to  wear  apparatus. 

Bow  Legs. 

Bow  legs  is  the  name  applied  to  the  opposite  deformity  to  knock- 
knee,  which  is  an  outward  angular  deformity  of  the  knee,  or  a 
general  outward  bowing  of  the  legs,  so  that  when  the  patient  stands 
erect  with  the  heels  together,  the  knees  are  a  greater  or  less  dis- 
tance apart. 

The  condition  is  also  known  as  genu  varum,  genu  extrorsum, 
out-knee,  bowed  legs  or  bandy  legs.  In  German  one  speaks  of  it 
as  Sabelbein,  Sichelbein,  Obein,  and  in  French  as  Genou  en  dehors. 

It  is  single  or  double,  generally  the  latter,  and  ma}-  exceptionally 
exist  in  one  leg  where  knock-knee  is  present  in  the  other. 

Occurrence. — The  deformity  is  almost  always  the  result  of  an 
outward  yielding  of  the  long  bones  of  the  leg,  especialh'  of  the 
tibia.     At  times,  however,  it  is  clearly  due  to  an  obliquity  at  the 

'  Cent.  f.  Chir.,  1SS2,  ii.,  S78. 

-  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  Paris,  1SS3,  ix. ,  SS5. 


672 


ORTHOPEDIC  SURGERY. 


knee-joint,  where  the  external  condyle  appears  the  larger  of  the 
two.  The  latter  condition  alone  is  very  uncommon,  but  it  is  prac- 
tically always  present  in  advanced  bow  legs,  because  when  once 
there  is  angle  enough  between  the  bones  of  the  leg  to  throw  the 
body  weight  chiefly  upon  the  inner  condyle,  it  atrophies,  while  the 
outer  one  increases,  and  exactly  the  opposite  condition  to  knock- 
knee  is  produced. 

The  anatomical  changes  found  are  those  of  rickets.     The  bend- 
ing of  the  bones  is  in   most  cases,   like  the  other  deformities  of 


Fig.  648. — Bow  Legs. 


Fig.  649. — Shape  of  the  Bones  in  Bow  Legs. 


rickets,  a  simple  yielding  without  fracture  or  destruction  of  bone 
tissue.' 

Causation. — Bow  legs  is  essentially  a  rhachitic  deformity  and 
true  bow  legs  can  only  occur  in  a  child  whose  bones  are  soft 
enough  to  bend  easily.  It  occurs  almost  exclusively  in  the  first 
three  or  four  years  of  life,  and  ordinarily  in  connection  with  general 
rickets ;  sometimes,  however,  other  rhachitic  manifestations  are 
absent;  but  the  yielding  of  the  bones  in  a  child  of  this  age  must  of 
itself  be  accounted  sufficient  evidence  of  rickets. 

Bow  legs  of  a  marked  type  is  seen  in  children  who  are  too  young 

'  Kassowitz  :    "  Die  Symptome  der  Rachitis,"  Cent.  f.  Chir.,  1887,  p.  179. 


KNOCK-KNK/C  AND   BOW  Ll'AJS. 


^V3 


ever  to  have  borne  their  weight  upon  tlicir  le^s.  'Jo  account  for 
it  by  any  such  pressure  upon  the  bones  as  they  would  be  hkely  to 
get  from  the  mother's  arm  in  a  constantly  changing  position  seems 
inadecjuate.  The  explanation  which  is  now  received,  is  that  the 
tonic  action  of  the  muscles  of  the  legs  has  been  sufficient  to  pro- 
duce this.  Kassowitz  goes  so  far  as  to  assert  that  muscular  tonus 
is  the  chief  factor  in  producing  deformity  of  the  legs,  and  that 
body  weight  comes  in  only  as  an  incidental  agent.  This  is  mani- 
festly going  too  far,  because  most  children  do  not  develop  bow  legs 


'<'!/ 


Fig.  650.— Standing  Position  of  Child       Fig.  651. — Diagram  Showing 
with  Bow  Legs.    Moderate  Grade.  Line  of  Weight  Bearing. 


Fig.  652. — Attitude  in  Slight 
Degree  of  Bow  Legs. 


while  they  are  in  arms  and  it  can  be  seen  in  most  cases  to  follow 
very  soon  upon  the  child's  learning  to  stand  and  w^alk.  On  the 
other  hand  it  is  not  to  be  found  in  children  who  walk  very  early, 
for,  associated  as  this  condition  is  with  rickets,  bow-legged  children, 
as  a  rule,  learn  to  walk  later  than  others.  Early  walking,  therefore, 
so  much  talked  about  as  a  cause  of  bow  legs,  is  not  to  be  accounted 
a  factor  of  any  importance  in  their  production. 

Why  the  bones  should  bend  outward  as  they  do  is  a  question 
which  has  caused  much  speculation,  and  which  is  by  no  means 
settled.     It  is  a  clinical  fact  that  children  with  severe  rickets  stand 


674 


ORTHOPEDIC  SURGERY. 


with  the  back  arched  and  the  thighs  sHghtly  flexed.  This  is  prob- 
ably either  on  account  of  the  weakness  of  the  rhachitic  muscles,  or 
because,  as  Mr.  Lane  suggests,  the  sacrum  has  rotated  forward 
and  to  keep  the  proper  relation  to  the  hip-joints,  the  pelvis  was 
forced  to  rotate  backward  on  a  transverse  axis,  which  has  shortened 
the  ilio-femoral  ligaments  and  necessitated  flexion  of  the  thighs  in 
the  erect  position.  It  is  not  altogether  a  satisfactory  explanation. 
However  that  may  be,  one  has  to  admit  the  fact,  that  clinically 

the  child  with  rickets  stands  with 
thighs  flexed  and  the  lumbar  spine 
arched  forward;  once  given  this  con- 
dition it  is  easy  to  see  how  bow  legs 
arise.  As  the  thighs  flex  the  knees 
are  separated  and  the  femurs  rotate 
outward  on  their  own  axes;  as  a  re- 
sult of  this  the  line  of  gravity,  instead 
of  falling  outside  of  the  knee-joint,  as 


j-^ 


Fig.  653. — Characteristic  Attitude  in  a  Case  of 
Moderate  Bow  Legs,  Showing  Especially  the 
Position  Chosen  with  the  Feet  Far  Apart. 


Fig.  654. — Extreme  Curvature  of 
Bones. 


we  have  seen  was  the  case  in  the  normal  erect  position,  falls  to 
the  inside  of  it;  and  any  yielding  of  the  bones  of  course  must  take 
place  in  the  outward  direction.  With  the  yielding  of  the  bones 
the  line  of  the  legs  falls  further  and  further  outside  of  the  line  of 
gravity  and 'the  body  weight  continually  acquires  better  leverage 
to  bend  the  bones. 

Anterior  curvature  of  the  thigh  and  the  leg  bones  is  manifestly 
the  result  of  body  weight  coming  upon  a  flexed  limb  conjoined  to 
the  action  of  the  most  powerful  muscles  in  the  body  (the  flexor 
muscles  of  the  thigh)  pulling  in  the  same  direction. 


knock-knep:  and  now  lecs. 


675 


5jw//^;^«.— Subjective  symptoms  are  absent,  except  of  course 
the  symptoms  of  rickets.  Jkit  the  deformity  is  plainly  evident  and 
even  in  tiie  milder  cases  the  \i;a\\.  is  modified  in  a  characteristic 
way.  The  child  walks  with  a  distinct  waddle  and  generally  with 
the  feet  wide  apart  and  a  tendency  to  invert  the  toes;  even  in  so 
slight  a  case  as  that  shown  in  the  figure.  The  gait  in  bad  cases 
bears  the  closest  resemblance  to  the  waddling  gait  of  double  con- 
genital dislocation  of  the  hips,  except  that  it  is  rarely  so  severe. 
The  line  of  the  leg  lies  so  much  outside  of  the  line  of  the  centre  of 
gravity,  that  in  bearing  weight  on  the  left  leg,  for  instance,  the 
body  must  be  thrown  decidedly 
over  to  the  left  to  bring  it  over 
its  line  of  support ;  it  is  in  a 
measure  the  reverse  of  the  gait 
in  knock-knee.  This  lurching  is 
inevitable  with  each  step,  and, 
other  things  being  equal,  is  in  a 
degree  proportionate  to  the 
amount  of  curve  present. 

The  deformity  is  almost  always 
more  conspicuous  in  the  stand 


Fig.  655. — Anterior  Bow  Legs, 


Fig.  656. — Anterior  and  Outward  Bow  Legs. 


ing  position,  both  because  these  children  stand  with  the  legs  so  far 
apart  and  because  the  knee-joints  generally  yield  somewhat  in  a 
lateral  direction  when  the  body  weight  is  superimposed. 

Gradual  Curve  of  Femur  and  Tibia, — The  curve  is  most  often  a 
gradual  and  uniform  bowing  of  the  femur  and  tibia,  so  that  with 
the  feet  together  the  outline  of  the  legs  forms  an  oval  which,  in 
severe  cases,  approaches  a  circle.  A  second  class  of  cases  presents 
a  bowing  chiefly  in  the  lower  third  of  the  tibia  which  is  more  angu- 
lar in  character  and  the  femurs  are  practically  normal;  a  third 
class  presents,  either  alone  or  in  conjuntion  with  the  other  de- 
formities, a  bowing  forward  of  the  tibia  and  sometimes  of  the 
femur  also.     These  are  the  three  common  types  of  the  deformity, 


6/6 


OR  THOPEDIC  S  URGER  Y. 


but  very  many  variations  are  always  to  be  noted.     Except  in  the 
severest  cases  bowing  of  the  other  bones  is  not,  as  a  rule,  present. 

In  cases  where  the  bowing  is  extreme,  the  knee-joint  is  of  course, 
involved,  and  the  external  condyle  of  the  femur  is  abnormally  long. 
Except  in  very  severe  cases  this  is  not  a  factor  of  much  import- 
ance, inasmuch  as  the  bowing  in  the  bones  is  the  chief  fault  and  a 
correction  of  that  would  rectify  the  deformity.  But  at  other  times 
the  deformity  lies  chiefly  in  the  knee-joint  and  the  bones  are  com- 
paratively straight. 


i^'  ' 


Fig.  657. — Gradual  Curve  of 
Femur  and  Tibia. 


Fig.  658. — Curve  of  Tibia,  Femur  but  Little  Affected. 


Very  rarely  one  sees  the  condition  of  knock-knee  and  bow  leg 
existing  in  the  same  leg. 

The  feet  in  cases  of  well-marked  bow  legs,  like  the  feet  of  all 
rhachitic  children,  are  in  a  condition  of  flat-foot  in  nearly  all  cases. 
They  are  inverted  in  walking,  apparently  not  so  much  from  any 
change  in  the  axis  of  the  leg  bones,  as  from  an  instinctive  effort  to 
have  the  base  of  support  as  far  toward  the  median  line  as  possible; 
an  end  which  is  accomplished  by  inverting  the  feet. 

The  bones  of  children  in  the  active  stage  of  bow  legs  are  thought 
to  possess  an  abnormal  degree  of  elasticity,  a  "  springiness  "  it  is 
commonly  called,  and  much  importance  is  attached  to  this  in  de- 
termining whether  or  no  the  stage  of  eburnation  has  begun.  One 
obtains  this  by  grasping  the  upper  part  of  the  tibia  and  the  knee- 


KNOCK-KNEJC  AND   HOW  LEGS.\ 


^>77 


joint  with  one  IkuuI,  while  with  t!ie  other  the  h)wer  end  of  tlie  tibia 
is  pressed  gently  outward  with  a  ({uick  movement,  and  a  sensation 
as  if  of  an  elastic  yielding  is  felt,  liut  it  is  doubtful  how  much 
importance  should  be  attached  to  this,  and  to  a  certain  degree  the 
sensation  is  misleading  and  can  be  obtained  in  normal  limbs.  One 
is  not  dealing  directly  with  the  bone,  but  with  a  bone  imbedded  in 
soft  and  elastic-feeling  muscles,  and  also  it  is  impossible  to  lu^ld  tiie 
knee  so  tightly  with  the  hand  as  to  exclude  the  elasticity  of  the 
Hgaments  of  the  knee-joint  when  pulled  upon. 

Diagnosis. — The  condition  of  bow  legs  is 
evident  on  inspection,  and  any  outward  cur- 
vature constitutes  bow  legs  just  as  any  in- 
ward curvature  is  knock-knee.  Macewen's 
definition  applied  to  this  deformity  would 
be,  that  it  was  a  condition  in  which  a  line 
drawn  from  the  head  of  the  femur  to  the 
middle  of  the  ankle-joint  would  fall  inside 
of  the  centre  of  the  knee-joint. 


Fig.  659. — Anterior  Curve  of  Femur 
with  Outward  Bowing  of  Tibia. 


3 

Fig.  660. — Bow  Legs  with  Deformity 
Chiefly  at  Knee-joint. 


Fig.  661. — Flat-foot  in 
Bow  Legs. 


It  must  be  remembered  in  making  the  diagnosis  that  the  deform- 
ity is  not  uncommonly  found  in  children  who  have  not  walked ; 
and  that  the  general  signs  of  rickets  may  be  very  slight,  although 
they  are  hardly  likely  to  be  entirely  wanting. 

It  is  often  difficult  to  determine  how  much  of  the  deformity  lies 
in  the  tibia  and  how  much  in  the  femur.  If  the  legs  are  crossed 
until  the  insides  of  the  knees  are  together  when  the  child  is  in  a 
sitting  position,  it  will  be  seen  whether  the  femurs  include  an  o\-al 
space  between  them,  or  are  parallel  to  each  other.  The  only  con- 
dition with  which  bow  legs  is  likely  to  be  confounded  is  double 
congenital  dislocation  of  the  hip  in  young  children,  a  question 
already  discussed  in  the  chapter  on  congenital  dislocation. 


67Z 


ORTHOPEDIC  SURGERY. 


Prognosis. — The  prognosis  in  bow  legs  is  favorable.  The  pros- 
pect of  spontaneous  outgrowth  of  the  deformity  is  much  better 
than  in  knock-knee,  and  in  young  children  rational  mechanical 
treatment  offers  almost  sure  relief.  The  prognosis  of  bow  legs 
when  untreated,  will  be  considered  more  in  detail  in  speaking  of 
the  treatment  by  expectancy.  Mechanical  treatment  is  not  likely 
to  benefit  cases  of  anterior  bowing  except  very  slight  ones.  Ope- 
rative treatment  can  ameliorate  almost  any  condition  of  deformity 
and  often  entirely  rectify  it. 

Treatment. — The  treatment  of  bow  legs,  like  that  of  knock-knee, 
is  to  be  considered  under  three  heads:  {a)  expectant,  {b)  mechani- 
cal, {c)  operative. 

{a)    The  expectant  treatment  is  suited  to  a  large  percentage  of 


Fig.  662. — Tracing  of  Bow  Legs  Showing  a  Case 
wliere  Curve  is  Mostly  in  Tibia. 


Fig.  663. — Tracing  of  Bow  Legs,  Showing  a  Case  of 
Gradual  Curve  Involving  the  Whole  Leg. 


cases  of  the  deformity,  and  its  range  of  applicability  is  much  wider 
than  in  knock-knee  because  bow  legs  show  a  more  decided  tendency 
toward  spontaneous  improvement.  The  mechanical  conditions  are 
not  so  much  in  favor  of  the  increase  of  the  deformity  as  in  knock- 
knee,  and  if  the  osseous  softening  stops  early  enough  the  tendency 
in  slight  cases  is  toward  rectification  in  the  course  of  growth.  In 
general,  where  the  curve  is  uniform,  involving  femur  and  tibia 
alike,  the  chances  are  more  favorable  for  spontaneous  cure  than  if 
the  deformity  is  localized  in  the  tibia  and  more  angular. 

The  difference  between  a  gradual  bowing  of  the  legs  and  a  sharp 
angular  curvature  of  the  tibia  can  be  best  appreciated  by  taking  a 
tracing  of  the  legs  in  the  simple  way  already  described.  The  dia- 
gram (Figs.  662  and  663)  shows  the  difference  in  the  outline  which  is 
easily  to  be  appreciated.  Apparently  this  is  an  important  matter 
in  the  prognosis. 


KNOCK-KNFJi  AND   BOW  LEGS. 


679 


The  figures  show  some  tracings  taken  at  random  from  out-patient 
cases  treated  by  expectancy,  attending  at  the  Children's  Ilosijital. 
The  parents  were  either  unvviHing  to  begin  mechanical  treatment 


Fig.  664.  Fig.  665.  Fig.  666. 

Figs.  664,  665,  666. — Tracings  from  a  Case  of  Bow  Legs  Showing  the  Progress  in  Three  Years  under 
Expectant  Treatment. 

or  were  negligent  about  it;  but  at  the  end  of  three  or  four  years 
the  children  were  sent  for  as  a  matter  of  curiosity;  and  two  repre- 
sentative cases  are  presented  in  the  figures.  Neither  of  these  had 
any  treatment  whatever,  and  there  is  no  reason  to  believe  that  these 


Fig.  667.  Fig.  668. 

Figs.  667,  668.- -Tracings  from  a  Case  of  Bow  Legs  Untreated.     Four  Years'  Inter\'al  Between  the 

Two  I'racmgs. 

are  exceptional  cases;  in  fact,  many  other  figures  of  the  same  im- 
port might  be  given  from  the  hospital  cases.  In  these  cases  me- 
chanical   treatm.ent    was    advised    when   the    children    first    came. 


68o 


ORTHOPEDIC  SURGERY. 


Fig.  669. 


Usually  there  seems  a  strong  tendency  toward  the  spontaneous 
outgrowth  of  bow  legs,  but  at  present  our  information  on  the  sub- 
ject is  too  meagre  to  make 
it  possible  to  allow  cases  to 
go  untreated. 

It  does  not  seem  worth 
while  to  show  figures  of  the 
results  of  mechanical  treat- 
ment, most  of  which  are 
equally  favorable,  but  cer- 
tainly no  results  can  be  bet- 
ter than  those  shown  as  the 
result  of  expectancy. 

The  number  of  men  with 
bow  legs  to  be  seen  in  the 
street  as  observed  by  Whit- 
man was  400  out  of  2,000. 
It  is  evident,  therefore,  that 
all  cases  of  bow  legs  do  not 
spontaneously  recover.  For 
this  reason  it  is  far  safer  to 
treat  cases  of  bow  legs  of 
any  severity,  especially  when 
chiefly  tibial,  by  mechanical 
measures,  always  bearing  in 
mind  the  fact  that  there  is  a 
likelihood  of  their  complete 
recovery  without  any  treat- 
ment whatever.  Some  tim.e. 
it  may  be  possible  to  say  in 
advance  what  cases  will  re- 
cover of  themselves.  At 
present  it  is  not  so,  and  if 
one  were  to  speak  from  the 
observation  of  children  alone, 
it  would  seem  safe  in  many 
cases  to  trust  to  nature;  but 
the  large  number  of  bow-leg- 
ged adults  must  serve  as  a 
warnine  and  in  cases  of  more 


Fig.  670. 

Figs,  ^ieg,  670.— Various  Forms  of  Elastic  Traction 

Splints  for  tiie  Correction  of  Bow  Legs. 


than  a  slight  degree,  it  is  decidedly  safer  to  begin  mechanical  treat- 
ment while  the  bones  are  soft. 

When  the  deformity  is  extreme  or  the  bones  are  eburnated,  it  is 
not  of  course  likely  that  the  child  will  outgrow  the  bow  legs.     It  is 


KNOCK-KNEE  AND   HOW  LEGS. 


68  r 


only  in  young  children  that  one  is  justified  in  expcctinj,^  it.  Ex- 
pectant treatment  should  only  be  pursued  when  the  child  can  be 
kept  under  observation  and  tracings  of  the  legs  can  be  taken  suffi- 
ciently often  to  see  whether  or  not  the  deformity  is  increasing. 
Any  increase  of  deformity  is  an  imperative  indication  for  mechan- 
ical treatment. 

During  expectant  treatment  the  general  condition  should  be 
most  carefully  attended  to  and  rickets  treated  very  vigorously 
from  the  first.  The  child  should  be  encouraged  to  be  off  of  his 
feet  as  much  as  possible,  and  the  legs  should  be  rubbed  and  man- 
ipulated each  night ;  being  gently  bent  toward  a  straight  direction. 


Fig.  671. 


Fig.  672. 


In  all  cases  tracings  should  be  taken  at  least  once  each  month, 
to  determine  if  the  deformity  remains  stationary  or  is  improving, 
and  if,  after  several  months  no  improvement  is  evident,  mechanical 
treatment  should  be  begun. 

(p)  Mechanical  treatment  is  based  upon  the  principle  of  drawing 
the  knee  inward  to  a  rigid  or  elastic  rod  which  has  counter  points 
for  sustaining  outward  pressure  at  the  upper  part  of  the  thigh  and 
the  ankle.  Here,  as  in  knock-knee,  traction  from  a  rigid  rod  is 
more  definite  and  more  satisfactory  than  from  an  elastic  one.  The 
form  of  apparatus  used  is  of  little  consequence  so  long  as  it  an- 
swers the  indications  and  holds  the  knee  extended.     It  is  no  longer 


682 


OR  THOPEDIC  S  URGER  V. 


customary  or  allowable  to  treat  these  cases  by  recumbency.  A 
simple  padded  inside  wooden  splint,  to  which  the  legs  are  band- 
aged, is  advocated  by  Noble  Smith. 

The  apparatus  shown  in  Fig.  671  is  the  one  generally  in  use  at 
the  Children's  Hospital  in  Boston,  and  is  in  every  way  serviceable 
and  economical.  It  consists  of  a  light  but  rigid  steel  upright, 
which  is  attached  below  to  the  sole  plate  of  the  shoe.  It  runs  up 
nearly  to  the  origin  of  the  adductor  muscles,  but  it  must  fall  a 
little  short  of  them  or  it  will  excoriate  the  skin  in  walking.  The 
upright  is  then  bent  forward  and  upward,  and  curved  to  fit  into 
the  groin  and  come  up  as  far  as  the  posterior  part  of  the  dorsum 
of  the  ilium.     In  this  way  a  lever  is  provided  with  which  to  evert 


l^'lG.  673. 

Figs.  673, 


Fig.  674. 
-Splints  for  Bow  Legs. 


the  feet  to  any  extent  by  altering  the  curve  of  their  arm,  and 
strapping  them  together  behind.  Pads  for  the  outside  of  the  legs 
are  made  of  leather  and  buckled  by  two  or  three  straps  to  the 
upright,  opposite  the  greatest  convexity  of  the  curve.  In  severe 
cases  it  is  advisable  to  have  a  flat  steel  pad  plate  covered  with 
leather,  where  the  upper  part  of  the  upright  bears  against  the 
thigh.  Where  the  curve  is  wholly  in  the  tibia  and  the  child  does 
not  "  toe  in  "  it  is  sufificient  to  carry  the  upright  just  above  the 
knee,  and  to  end  it  in  the  semicircular  pad  plate  which  is  applied 
against  the  inner  part  of  the  thigh. 

Anterior  tibial  curves  are  not  susceptible  of  improvement  or 
cure  by  mechanical  treatment  except  in  very  slight  cases  where 
the  bones  are  soft  and  the  curve  very  slight.  In  these  cases  it  is 
useful  to  apply  to  the  foot  a  steel  sole  plate  with  a  cup-shaped 


KNOCk'-KNl'lE  ANJj   L'OIV  LKCS.  533 

rim  to  the  heel,  formin^^  its  posterior  border.  To  tliis  twcj  uprij^hts 
are  attached  and  an  anterior  pad  pulls  the  lower  part  of  the  tibia 
backward,  pulling  from  these  uprights.  In  general,  however,  it  is 
not  advisable  to  apply  apparatus  to  anterior  bow  legs. 

An  elastic  brace  is  figured  and  described  by  Roberts  similar  to 
the  one  used  by  him  in  the  treatment  of  knock-knee. 

The  mechanical  treatment  of  bow  legs  should  be  advised  in 
cases  in  which  the  deformity  is  severe  or  sufficiently  obstinate  to 
make  it  doubtful  whether  spontaneous  outgrowth  of  the  deformity 
Avill  occur,  because  braces  do  no  harm,  and  do  not  retard  sponta- 
neous improvement.  The  best  applicability  of  the  treatment  is  to 
children  under  three  years  of  age  and  after  that  when  the  bones 
seem  yielding.  After  the  age  of  three  or  four  it  is  not  generally 
worth  while  to  begin  mechanical  treatment.  Mechanical  treatment 
can  be  delayed  longer  in  cases  where  the  curve  involves  the  whole 
leg  than  where  it  is  localized  in  the  tibia.  Children  who  are  too 
old  for  mechanical  treatment  can  either  be  operated  upon  at  once 
or  allowed  to  wait  as  long  as  one  wishes  for  operation,  for  in  ebur- 
nated  and  hardened  bones  the  deformity  will  not  grow  any  worse. 

In  the  case  of  babies  the  expectant  plan  of  treatment  is  the  one 
to  be  followed  at  first.  Careful  tracings  of  the  legs  should  be 
taken  and  the  bones  gently  bent  toward  a  straight  direction.  Es- 
pecially important  is  the  treatment  of  the  general  rickets  which 
will  be  found  present.  If  after  two  or  three  months  the  deformity 
is  found  to  be  increasing  or  stationary,  mechanical  treatment  m.ust 
be  begun  with  the  application  of  some  splint  drawing  inward  upon 
the  leg.  Photography  gives  a  less  accurate  record  of  the  condition 
than  the  simple  tracings  with  the  lead  pencil  described  above. 

{c)  Opcj'ative  Treatment  of  Bozv  Legs. — Mechanical  treatment  for 
bow  legs  is  useless  after  the  bones  have  become  thoroughly  ossified, 
as  the  normal  bone  is  stronger  than  a  steel  appliance  which  can  be 
applied  and  worn.  If,  therefore,  the  legs  are  very  much  curved 
and  the  bones  are  resistant,  the  curvature  must  be  allowed  to  re- 
main untreated  or  the  patient  must  submit  to  operative  treatment. 
A  certain  number  of  severe  curves,  as  has  already  been  shown,  im- 
prove Avith  growth,  but  there  is  a  limit  to  the  power  of  the  correct- 
ing power  of  growth,  and  if  ossification  of  the  shaft  has  been  well 
established,  there  is  little  or  no  probability  of  farther  correction 
by  natural  means.     The  operative  procedures  are: 

Osteoclasis. 

Osteotomy. 

Osteostomy. 

Osteoclasis  can  be  either  manual  or  by  the  aid  of  mechanical 
appliances. 


684 


ORTHOPEDIC  SURGERY. 


The  manual  fracture  of  bones  is  a  procedure  which,  though  an 
old  one,  is  not  to  be  recommended. 

Much  force  is  required  even  in  the  case  of  the  bones  of  young 
children,  and  it  is  impossible  to  fracture  by  manual  force  alone 
bones  which  are  thoroughly  ossified. 

Manual  fracture  also  lacks  precision  as  to  the  point  of  breaking. 
For  these  reasons  the  method  is  hardly  to  be  commended.  In  the 
case  of  bones  still  soft,  if  it  is  desired  to  operate  at  that  stage, 
manual  fracture  has  a  place  in  the  operative  treatment,  but  even 
then  manual  fracture  presents  no  advantage  over  the  osteoclasts, 
and  it  lacks  the  precision  of  those  instruments. 

Mechanical  fracture  is  made  feasible  by  the  use  of  ostecolasts,  of 
which  the  one  of  Rizzoli  is  the  most  convenient.     The  appliance  is 


Fig.  675. — Rizzoli's  Osteoclast. 


easily  understood  from  the  accompanying  illustration.  The  in- 
strument is  made  of  heavy  steel,  and  the  rings  and  the  screw  pad 
all  slide  on  the  bar  so  as  to  be  adjustable  to  any  length  of  leg. 
The  parts  of  the  apparatus  which  come  in  contact  with  the  leg  are 
padded  so  that  the  edges  shall  not  cut. 

Osteoclasis  is  a  simple  procedure.  The  instrument  is  applied  to 
the  bared  limb,  the  rings  being  adjusted  as  far  as  is  possible  from 
t-he  point  at  which  fracture  is  desired.  The  screw  force  is  to  be 
adjusted  so  as  to  press  at  the  point  of  election  for  fracture,  which 
is  at  the  point  of  the  greatest  convexity  of  the  curve.  Pressure 
is  increased  until  fracture  of  the  bones  takes  place.  The  fibula 
breaks  first,  the  tibia  shortly  afterward  on  continuing  the  screw 
pressure.  The  fracture  of  the  bones  is  evidenced  by  a  loud  snap 
which  can  be  heard  anywhere  in  the  room. 


KNOCk'-KNI'll':  AND    JHJW  JJ'AJS. 


685 


The  amount  of  force 
which  will  be  required  be- 
fore fracture  takes  place 
is  surprisingly  great.  The 
bone  will  usually  be  found 
to  bend  to  a  great  degree 
before  fracture  occurs. 
If  the  instrument  is  well 
padded  there  will  be  no 
danger  of  injury  of  the 
skin  from  the  temjDorary 
pressure  necessary  for 
fracture,  although  the 
amount  of  this  pressure 
may  be  very  great.  The 
skin  will  becomeblanched 
or  congested,  but  after 
the  removal  of  the  osteo- 
clast the  color  will  be 
found  normal,  with  but 
slight  evidence  of  pres- 
sure. 

The  fracture  M'ill  be 
found  to  have  taken  place 
opposite  to  the  screvv- 
pad  plate. 

After  the  bone  has  been 
broken,  the  osteoclast 
should  be  removed ;  the 
fragments  placed  with 
the  hand  in  the  desired 
position,  without  any  un- 
necessary stirring  up  of 
the  bones  at  the  seat  of 
fracture  ;  sheet  wadding 
is  placed  on  the  leg,  and 
the  limb  fixed  in  a  gyp- 
sum bandage  and  held  in 
a  carefully  corrected  po- 
sition. The  bandage 
should  reach  from  the 
toes  to  the  hip,  and  the 
limb  should  be  held  in 
the     corrected     position 


Figs.  676,  677. 


Fig.  677. 
-Bow  Less  Corrected  bv  Osteoclasis. 


686  ORTHOPEDI-C  SURGERY. 

until  the  plaster  has  hardened  thoroughly.  When  there  is  a  rota- 
tion of  the  tibia  as  well  as  a  curvature,  care  should  be  taken  to 
see  that  it  also  is  remedied  and  that  the  limb  is  fixed  in  a  normal 
position. 

The  dangers  from  osteoclasis  are  more  imaginary  than  real. 
Experience  has  shown  that  the  procedure  is  ordinarily  free  from 
risk.  The  skin  does  not  slough  under  the  pressure  and  there  is  no 
danger  of  sepsis;  and  in  properly  selected  cases- the  danger  of  non- 
union after  fracture  may  be  disregarded  as  slight.  The  fracture  is 
a  transverse  one  and  there  is  no  danger  of  splintering  of  the  bone. 
A  number  of  experiments  upon  the  cadaver  were  made  by  the 
writers  with  reference  to  this  point  and  it  was  found  that  although 
splintering  will  take  place  in  dry  bone  if  subjected  to  fracture  by  an 
osteoclast,  yet  bone  undried,  as  found  in  the  dissecting  room,  will 
break  transversely;  the  fracture  takes  place  as  a  sharp  linear  frac- 
ture half  way  through  the  bone.  The  part  of  the  bone  nearest  the 
side  of  pressure  breaks  with  an  irregular  line  of  fracture,  as  if  torn. 

The  amount  of  force  required  for  the  fracture  of  an  adult  bone 
is  very  great,  so  much  so  as  to  make,  in  most  instances,  osteotomy 
a  preferable  procedure. 

Osteoclasis  near  the  joints  is  difficult,  but  in  the  shaft  of  the 
tibia  the  operation  is  a  most  excellent  one,  yielding  most  satisfac- 
tory results  with  but  little  discomfort  to  the  patient. 

In  the  large  number  of  cases  of  osteoclasis  which  have  come  in 
the  experience  of  the  writers  at  the  Boston  Children's  Hospital 
there  have  been  no  cases  in  any  way  unsatisfactory  in  the  results. 
Cases  should  not  be  operated  upon  unless  the  bones  are  fairly 
strong — that  is,  if  the  rhachitic  process  has  not  been  well  arrested 
— as  recurrence  of  the  deformity  may  take  place.  This  has  oc- 
curred a  few  times  in  the  experience  of  the  writers,  and  a  second 
operation  has  been  necessary,  but  such  cases  are  very  rare,  and 
have  only  served  to  emphasize  the  necessity  of  avoiding  too  early 
an  operation. 

Cases  have  been  operated  on  as  young  as  three  years,  but  as  a 
rule  the  operation  should  not  be  performed  before  the  age  of  four. 

The  limb  should  remain  in  a  fixed  bandage  for  four  or  five  weeks, 
and  no  appliance  is  needed  as  an  after-treatment. 

Anterior  Bow  Legs. — In  the  treatment  of  anterior  bow  legs  the 
tibia  may  be  broken  by  the  osteoclast  applied  in  the  usual  way, 
and  after  the  fracture  has  been  loosened  by  the  hands  the  leg  may 
be  set  straight.  Osteotomy,  however,  as  a  rule  is  more  satisfactory 
in  these  cases.  Osteoclasis  is  not  satisfactory  in  curvatures  near 
joints. 

The   osteoclast   of  Colin   may,  perhaps,  be   used   to  break  bones 


KNOCK- KNEE  AND   nOW  LEGS. 


687 


nearer  the  joints  than  can  be  clone  with  the  RizzoH  instrument, 
but  the  CoHn  apparatus  is  compHcated,  cumbersome,  and  expensive. 
It  is  worked  by  a  block  and  tackle  as  seen  in  the  diagram. 

Osteotomy  should  be  employed  in  place  of  osteoclasis  in  cases 
of  bow  legs  (i)  where  the  curvature  is  so  near  the  joint  that  osteo- 
clasis is  not  practicable.  (2)  Where  the  bone  is  so  strong  that 
osteoclasis  is  not  feasible.  (3)  Where  several  curves  exist  in  the 
same  leg,  or  where  the  curvature  is  anterior.  (4)  In  cases  of  bow 
leg  where  the  distortion  is  largely  in  the  lower  epiphysis  of  the 
femur. 

Osteotomy  for  bow  legs  is  a  similar  operation  to  that  for  knock- 
knee  ;  the  division  of  bone  being  made  wherever  it  appears  most 
necessary,  and  no  formal  operation  can  be  laid  down.     In  young 


n'^  ( )-,teoclast. 


children  the  fibula  need  not  be  cut  with  the  chisel,  but  will  break 
after  the  greater  part  of  the  tibia  has  been  chiselled  A\hen  manual 
pressure  is  applied.  Osteotomy  will  in  general  offer  the  best  treat- 
ment for  anterior  bow  legs.  The  tibia  should  be  cut  nearly  through 
at  the  level  of  the  greatest  angularity  and  the  limb  fractured,  and 
tenotomy  of  the  tendo  Achillis  will  generally  be  an  aid  to  the  rec- 
tification of  the  foot.  It  is  not  necessary  to  remove  a  wedge  of 
bone  except  in  very  severe  cases,  simple  linear  osteotomy  answer- 
ing every  purpose. 

Osteostomy,  or  the  removal  of  a  wedge  of  bone,  is  rarely  needed 
in  bow  legs,  unless  accompanied  by  sharp  angular  curves  of  the 
tibia,  where  a  removal  of  a  wedge-shaped  piece  of  bone  is  necessary 
to  straighten  the  limb. 

A  practical  way  to  determine  the  amount  of  bone  to  be  removed 
is  the  following :    an  outline  of  the  leg  is  taken  b)'  means  of  a  trac- 


688 


OR  THOPEDIC  S  URGER  V. 


ing  drawn  on  paper  and  then  cut  out.  If  a  wedge-shaped  section  of 
this  profile  of  the  leg  be  made  and  enough  removed  that  the  leg 
be  straight,  the  paper  wedge  will  indicate  the  amount  of  the  tibia 
which  needs  removal. 

After  osteotomy  it  is  not  usually  necessary  to  wire  the  fragments 
of  bone  together,  but  if  they  are  placed  in  apposition  and  fixed, 
union  can  be  expected  to  take  place. 

A  free  skin  incision  is  of  course  necessary  for  the  removal  of  a 
wedge  of  bone  from  the  tibia,  and  the  periosteum  should  be  incised 
and  scraped  away  from  the  .proposed  seat  of  operation  with  very 
great  care  and  after  the  removal  of  the  wedge,  it  should  be  stitched 


Fig.  679. — Original  Condition  of  Patient. 


Fig. 


-Slight  Grade  of  Knock-knee  Seen  After 
Osteotomy  for  Bow  Legs. 


carefully  together.  In  simple  linear  osteotomy  no  skin  incision  is 
necessary  in  any. 

A  very  unusual  result  from  an  osteotomy  for  bow  legs  is  seen  in 
Figs.  679,  680.  The  patient  convalesced  very  nicely  from  the 
operation  and  in  a  year  or  so  afterward  appeared  with  slight  knock- 
which  has  been  remedied  by  apparatus.  There  was  no  suggestion 
knee  of  over-correction  at  the  time  of  operation  and  the  case  is 
only  of  interest  in  showing- the  possibility  of  such  an  occurrence. 

Ultimate  Results  of  Osteotomy  and  Osteoclasis. — Dr.  J.  E.  Gold- 
thwaite  has  recently  traced  out  twenty-eight  cases  of  knock-knee 
and  bow  legs  operated  on  in  the  Children's  Hospital,  not  taking  into 
account  any  case  operated  within  a  year  and  a  half  of  the  begin- 
ning of  his  investigation.  There  were  eleven  cases  of  Macewen's 
osteotomy  for  knock-knee  and  eleven  of  osteoclasis  for  bow  legs, 
while  there  were  five  cases  of  anterior  bowine  of  the  tibia  treated 


KNOCK-KNl'lh:  AND    unw  I.I'.GS. 


689 


by  osteotomy.  The  average  length  of  time  after  the  operation 
was  four  years,  and  of  these  cases  only  one  had  relapsed.  That 
was  a  colored  boy  four  and  one-half  years  old  who  presented  a 
condition  of  extreme  rickets.  He  had  both  knock-knee  and  bow 
legs,  and  osteoclasis  and  osteotomy  were  done  and  the  knock-knee 
had  relapsed  since  operation,  and  now  he  presents  a  moderate  but 
marked  degree  of  knock-knee. 

The  figures,  which  are  taken  from  composite  tracings  of  each 
group  of  cases,  show  the  condition  of  these  patients  before  and 
after  operation. 

The  figure  showing  the  combined  results  in  knock-knees  and 
bow  legs  might  be  liable  to  misinterpretation,  inasmuch  as  the  de- 


FiG.  681. — Shows  a  Composite 
of  6  Tracings  of  the  Cases  of 
Knock-knee,  taken  when  the  pa- 
tients Applied  for  Treatment. 


Fig.  6S2. — Is  a  Composite  of  10 
of  the  Cases  of  Bow  Legs  Before 
Operation.  (No  tracings  were  ex- 
cluded in  making  these  groups.) 


Fig.  683. — Represents  a  Compo- 
site Tracing  of  the  End  Results 
at  Least  a  Year  After  Operation. 
With  the  exception  of  the  case  of 
relapse  above  mentioned,  all  of 
the  28  cases  are  represented  in 
this  tracing. 


formities  would  counteract  each  other,  but  the  legs  of  all  these 
children  were  perfectly  straight. 

The  average  age  at  the  time  of  operation  was  four  years.  The 
youngest  child  was  two  years  old  and  the  eldest  ten.  Chotzen  ' 
reported  the  ultimate  results  in  twenty-two  cases  operated  on  be- 
tween the  ages  of  fifteen  and  nineteen  years  with  excellent  results 
in  every  case. 

Non-Union  of  the  Bones. — Non-union  of  the  bones  is  very  rare 
after  either  osteotomy  or  osteoclasis.  Such  cases,  however,  occa- 
sionally occur,   as  in  a  case   reported   by   Marsh  to  the   Midland 


'  r>resl.  arztl.  Zeitsch. ,  No.  23. 


44 


690 


ORTHOPEDIC  SURGERY 


Medical  Society,  where  non-union  of  the  tibia  was  present.  In 
this  case  it  seemed  to  be  attributable  to  local  causes. 

No  precise  rules  can  be  laid  down  as  to  the  choice  between  these 
different  procedures  in  bow  legs. 

Osteoclasis  is  preferable  when  it  is  possible,  as  being  theoretically 
the  safer  operation,  though  practically  statistics  show  such  excellent 
results  in  osteotomy  that  a  choice  becomes  one  of  the  preference 


Fig.  6S4.  Fig.  685. 

Fig.  684  is  a  Composite  of  3  Cases  of  Anterior  Curvature  of  the  Femur,  while  Fig.  685  Represents  the 

End  Result  in  these  Cases. 


of  the  surgeon.  Osteoclasis  is  preferable  in  simple  tibial  curves 
of  young  children.  No  operative  procedure  is  advisable  before 
the  a§e  of  age  of  four.  Osteoclasis  is  unadvisable  in  adult  life, 
osteotomy  being  much  more  easily  done,  and  at  less  risk  to  the 
patient. 

The  limb  after  operation  may  be  fixed  by  wooden  splints,  wire 
splints,  etc.,  but  the  writers  much  prefer  plaster-of-Paris  bandages, 
as  giving  more  thorough  fixation  than  any  other  method. 


CHAPTER   XXI. 
TORTICOLLIS. 

Definition.  —  Etiology.  —  Varieties.  —  Pathological  Anatomy.  —  Symptoms.  — 
Diagnosis. — Prognosis. — Treatment. — Mechanical. — Operative. 

The  name  torticollis  is  given  to  that  distortion  of  the  head 
which  causes  it  to  be  held  awry,  and  this  condition  is  either  con- 
stant or  intermittent. 

The  names  by  which  this  affection  is  known  are  torticolHs,  wry 
neck,  caput  obstipum,  collum  distortum,  cou  tortu,  Schiefhals. 

Etiology. 

The  head  is  held  sideways,  from  pathological  reasons  or  from 
what  may  be  called  physiological  reasons.  Bouvier  states  that 
voluntary  torticollis  is  habitually  connected  with  different  temper- 
aments, and  that  in  fact  the  position  of  the  head  is  a  means  of 
expression  of  human  emotion,  a  fact  which  is  evident  in  watching 
any  actor.  Such  a  position  of  the  head  continued  habitually  would 
give  rise  to  what  may  be  termed  a  physiological  torticollis.  This 
does  not  merit  attention,  though  Millet  mentions  a  case  where 
such  a  torticollis  needed  treatment.  Torticollis  may  be  developed 
from  inequality  in  the  sight  of  the  two  eyes,  for  it  is  well  known 
that  the  eyes  are  often  of  unequal  power,  but  this  is  ordinarily 
overcome  by  accommodation.  In  a  few  cases  this  ocular  accom- 
modation is  aided  by  a  position  of  the  head,  and  a  class  of  wry 
neck  has  been  termed  by  Quignet,  torticollis  oculaire.  This  form 
is  extremely  uncommon. 

The  writers,  however,  have  observed  two  such  cases,  one  in  a  child 
of  five  where,  owing  to  a  great  difference  in  the  power  of  the  eyes, 
the  position  of  the  head  was  such  that  practicaily  but  one  eye  was 
used,  the  image  in  the  weaker  eye  being  disregarded. 

In  another  case,  a  picture  of  which  is  here  given,  owing  to  an 
irregularity  in  the  power  of  the  ocular  muscles  of  the  different  eyes, 
the  axes  of  the  eyes  were  on  different  planes,  and  a  distorted  posi- 
tion   of    the    head  constituting  torticollis    had    existed    for  years, 


692 


OR  THOPEDIC  S  URGER  V. 


for  which  various  treatment,  including  gymnastics  for  several  years, 
had  been  undertaken  without  effect.  Tenotomy  of  the  ocular 
muscles  corrected  the  muscular  irregularity  and  brought  the  axes 
of  the  eyes  to  the  same  plane  and  the  torticollis  was  permanently 
cured.  No  muscular  spasm  or  atrophy  could  be  detected  in  the 
muscles  of  the  neck  in  this  case.     The  possibility  of  syphilis  giving 


Fig. 


-Ocular  Torticollis  ;  Habitual  Position 
of  Head. 


Fig.  687. — Ocular  Torticollis ;  Back  View  of 
Habitual  Position. 


rise  to  torticollis  has  been  disputed.  In  the  only  instance  of 
gumma  of  the  sterno-mastoid  seen  by  the  writers,  no  wry  neck  was 
present. 


Varieties. 

The  affection  is  either  congenital  or  acquired. 

The  congenital  form  is  rare.  A  few  cases  have  been  noted  in 
which  an  imperfection  in  the  atlas  and  cervical  vertebrae  existed, 
in  consequence  of  which  the  head  was  held  in  malposition.  A 
more  frequent  cause,  however,  is  in  injury  to  the  nerve  centres,  or 
to  the  muscle  at  the  time  of  birth. 

Certain  instances  of  this  form  of  torticollis  are  undoubted,  and 
in  one  instance  observed  by  the  writers  torticollis  attributed  to  the 


'I'ORTJCOLJJS.  693 

use  of  forceps  during  labor  wr.s  accc)iii])anic(l,  in  a  boy  of  six,  by 
evidence  of  depressed  fracture  of  the  skull  from  the  use  of  fcjrcej^s. 

The  acquired  form  presents  several  varieties.  These  may  be 
grouped  into : 

Spastic. 

Paralytic. 

Compensatory. 

Idiopathic. 

Under  spastic  arc  included  those  cases  which  arise  from  a  direct 
nerve  irritation.  This  may  be  central,  situated  along  the  course  of 
the  nerve,  or  may  be  the  local  manifestation  of  a  more  general 
nervous  irritation  as  in  spinal  irritation.  In  some  cases  of  the 
spasmodic  form,  the  affection  is  closely  allied  to  writers'  cramp, 
spasmodic  tic  of  the  face,  etc.,  and  in  one  case  observed  there  was 
a  nodding  motion  to  the  head,  suggesting  a  small  patch  of  sclerosis. 

The  spasm  in  this  class  can  be  either  tonic  or  clonic,  but  cases 
in  which  such  nervous  lesions  can  be  determined  are  seldom  seen. 
A  local  cause  for  reflex  irritation,  such  as  disease  in  that  neighbor- 
hood, is  more  common,  as  disease  of  the  cervical  vertebras,  enlarge- 
ment of  the  cervical  glands,  deep  cervical  abscess,  or  simple  inflam- 
mation of  the  muscle.  Arising  from  a  cause  of  this  nature  the 
spasm  is  analogous  to  that  seen  in  any  diseased  joint. 

The  paralytic  variety  is  rarely  met  with. 

A  compensatory  wry  neck  arises  from  previously  existing  de- 
formity, on  account  of  which  the  position  of  the  head  is  unnatural, 
and  in  the  effort  to  correct  this  the  head  is  held  in  an  abnormal 
relation  to  the  shoulders.  This  has  been  seen  in  cases  of  lateral 
curvature. 

Frequently  no  definite  lesion  can  be  found  to  explain  the  occur- 
rence of  the  affection,  but  it  is  evidentl}'  the  result  of  general 
malnutrition  or  general  nervous  disturbance  having  this  as  a  local 
manifestation.  Not  infrequently  in  these  cases  there  will  be  found 
a  definite  exciting  cause,  such  as  fright,  grief,  etc.;  also  included 
under  this  head  are  those  acute  cases,  of  sudden  onset,  due  to  an 
inflammatory  condition  of  the  muscle  itself. 

Many  of  the  above  causes  seem  to  be  but  one  out  of  many 
factors.  In  a  large  per  cent  of  cases  there  will  be  found  to  be  a. 
neurotic  family  or  personal  history,  also  the  general  condition 
seems  to  have  a  very  considerable  influence;  many  cases  occur- 
ring after  severe  overwork,  in  this  particular  bearing  a  close 
analog}^  to  professional  cramp  or  spasm.  Instances  have  been  re- 
ported in  which  the  condition  appeared  after  excessive  use  of  the 
muscles  of  one  side  of  the  neck,  as  in  a  factory  girl  whose  occupa- 
tion required  her  to  turn  her  head  frequently  to  one  side.     It  has 


694 


ORTHOPEDIC  SURGERY. 


also  been  observed  in  seamstresses  who  had  worked  on  heavy  ma- 
terial. In  these  cases  fatigue  was  complained  of  on  the  side  of  the 
body  corresponding  to  the  hand  in  which  the  material  was  held. 

Torticollis  very  rarely  occurs  in  old  age,  but  is  more  common  in 
young  children.  The  male  sex  is  said  to  be  more  liable  to  the 
deformity  than  the  female,  but  this  may  be  considered  as  doubtful. 

Of  the  above-mentioned  forms  the  spastic  is  the  most  common. 

Wry  neck  due  to  old  dislocation  of  the  cervical  vertebrae  is  not 
a  common  variety,  but  cases  of  this  sort  have  been  observed. 

Pathological  Anatomy. 

In  the  acute  form  of  the  deformity  nothing  is  to  be  observed 
post  mortem.  In  the  chronic  form,  however,  of  whatever  cause, 
certain  important  changes  in  the  muscles  necessarily  follow. 

Fibrous  degeneration,  adaptive  shortening,  loss  of  tonicity,  and 
over-stretching  all  take  place  in  the  muscles,  as  well  as  the  second- 
ary shortening  and  lengthening  of  the  fasciae  around  the  bones. 

Alterations  in  the  shape  of  the  vertebral  bodies,  although  denied 
by  Bouvier,  exist  in  a  certain  number  of  cases,  but  this  osseous 
deformity  is  not  as  common  as  would  be  supposed.  The  muscle 
most  usually  affected  is  the  sterno-cleido-mastoid.  This  is  rarely 
affected  alone ;  but  being  a  terminal  muscle  it  is  more  usually 
noticed  than  the  contraction  of  the  others.  It  has  been  said  that 
the  sterno-cleido-mastoid  of  the  right  side  is  more  frequently 
affected  than  the  left,  and  Dieffenbach  found  in  37  cases  contrac- 
tion of  the  left  sterno-cleido-mastoid  in  only  9.  Bouvier,  out  of  27 
cases,  found  18  on  the  right;  and  Runis  claims  the  contraction  is. 
twice  as  common  on  the  right  side  as  on  the  left.  Bouvier  also 
found  that  in  three  cases  out  of  four  the  sternal  branch  of  the 
muscle  is  the  only  one  contracted.  But  the  sterno-cleido-mastoid 
is  not  the  only  muscle  which  is  affected;  in  fact  Delore  believed 
that  the  posterior  muscles  of  the  neck  were  the  chief  ones  affected 
in  18  out  of  22  cases,  and  they  certainly  are  affected  secondarily  if 
not  primarily  in  a  very  large  number  of  cases.  The  muscles  which 
may  be  involved  are  the  trapezius,  splenlus,  scaleni,  and  the  pla- 
tysma.  In  fact,  all  the  muscles  of  the  neck  take  part  in  severe 
cases.  A  peculiar  secondary  change  which  follows  long-continued 
torticollis  is  asymmetry  of  the  face.  This  facial  atrophy  is  explained 
in  several  ways.  First,  by  muscular  tension  ;  Second  ;  by  a  differ- 
ence in  the  blood  supply  on  the  different  sides ;  Third,  by  inter- 
ference with  the  function  of  the  parts,  and,  Fourth,  by  the  fact  that 
the  tension  of  the  soft  tissues  in  certain  parts  causes  pressure  and 
thus  hinders  development.     A  deviation  of  the  line  of  the  nose 


ruR  T/co/jjs.  695 

from  a  right  angle  to  tlic  line  of  the  eyes,  is  noticed;  furthermcjre 
the  distances  from  the  outer  point  of  the  two  eyes  to  the  outer 
corners  of  the  mouth  are  not  the  same,  while  the  cheek  on  the 
contracted  side  is  less  prominent  and  the  features  on  the  affected 
side  of  the  face  are  smaller  than  those  upon  the  other  side.  This 
asymmetry  diminishes  if  the  deformity  is  corrected  early. 

In  one  adult  case  described  by  Holmes  the  external  canthus  of 
the  eye  was  distant  from  the  external  angle  of  the  mouth  three 
inches  on  one  side,  while  on  the  other  side  the  distance  amounted 
to  three  and  one-half  inches.  The  inclination  of  the  head  to  the 
right  side  causes  the  right  eye  to  be  habitually  situated  on  a  lower 
plane  than  would  be  the  case  if  atrophy  of  the  affected  side  was 
present. 

Dubrueil  claims  that  the  cranium  itself  also  indicates  a  change, 
and  that  inequality  of  the  cerebral  hemispheres  of  the  different 
sides  results.  Bruen  concludes  from  this  that  a  diminution  of  intel- 
ligence would  necessarily  result,  but  this  is  contrary  to  clinical 
evidence.  Bouvier  found  in  an  autopsy  an  unequal  development  of 
the  carotid  arteries  in  one  autopsy  which  he  made. 

Another  change  is  lateral  curvature  of  the  spine  in  the  cervical 
region,  with  a  compensatory  curve  in  the  dorsal  region.  Asymme- 
try and  difference  in  length  of  the  clavicles  have  been  noted.' 

The  affection  involves  in  a  number  of  cases  the  distribution  of 
the  spinal  accessory  nerve.  The  sterno-mastoid  muscle  is  more 
usually  affected  than  the  others,  but  rarely  alone,  and  a  combina- 
tion of  the  spasmodic  action  of  several  muscles  usually  induces  the 
deformity.  Dieffenbach  relates  a  case  of  contraction  of  both 
platysina  muscles,  the  head  being  drawn  doAvnward.  Gooch  re- 
lates a  case  due  to  the  contraction  of  one  platysma,  A  simultane- 
ous contraction  of  the  sterno-mastoid  of  one  side  and  the  splenius 
of  the  other  has  been  observed.  A  contraction  of  the  scalenus 
anticus  alone  has  been  reported  by  Dubreuil.  The  small  vertebral 
muscles  and  the  longus  colli  have  been  reported  as  contracted, 
but  the  recognition  of  the  contraction  of  these  individual  muscles 
is  of  little  importance  to  the  surgeon. 

The  muscles  usually  involved  are  the  following:  The  anterior 
and  posterior  scaleni,  which  flex  and  incline  the  head  to  the  side 
of  the  contracted  muscle;  the  trapezius  and  splenius  which  ex- 
;  tend  the  head  {i.e.,  throw  it  backward);  the  complexus  extends 
the  head  and  turns  it  to  the  opposite  side.  The  following  three 
muscles,  when  contracted,  turn  the  head  to  the  opposite  side :  the 
sterno-mastoid,   the   trapezius,   and    the   complexus;    and  the  fol- 

'  Witzel  :  "  Secondary  Changes  in  Muscular  Torticollis,"  Deutsche  Zeitschrift  f.  Chin, 
Bd.  xviii.,  Heft  5  and  6,  page  335. 


696 


ORTHOPEDIC  SURGERY. 


lowing,  if  contracted,  draw  the  head  toward  the  side  of  the  con- 
tracted muscle :  the  scaleni,  the  splenius,  the  levator  anguli  scapulae, 
and  the  platysma.  A  contraction  of  both  sterno-cleido-mastoid 
and  of  the  clavicular  branch  of  the  trapezius  is  not  uncommon. 
This  can  be  .explained  from  the  fact  that  both  muscles  are  sup- 
plied from  the  same  nerve,  that  is,  the  branch  of  the  spinal  acces- 
sory. Physiologically,  the  splenius  muscle,  if  contracted,  would 
draw  the  head  to  the  side  and  turn  the  face  to  the  same  side.  This, 
according  to  Delore,  never  takes  place  in  torticollis.  It  is,  there- 
fore, assumed  that  the  sterno-mastoid  and  the  splenius  are  never 
affected  on  the  same  side.  Where  the  levator  anguli  scapulae  is 
affected  together  with  the  sterno-mastoid,  there  is  an  increase  in 
the  lateral  obliquity  and  of  the  rotation.  A  combination  of  the 
contraction  of  different  muscles  on  different  sides  has  been  ob- 
served. 

Duchenne  reports  a  simultaneous  contraction  of  the  splenius  and 
the  levator  anguli  scapulae ;  Dubrueil,  that  of  the  scalenus  anticus 
and  of  the  splenius.  According  to  Volkmann,  irritation  of  the 
spinal  accessory  nerve  in  rabbits  in  its  passage  through  the  fora- 
men lacerum  causes  spasm  in  the  muscles  usually  affected.  But 
there  is  no  evidence  that  this  fact  has  any  pathological  value  as  ap- 
plied to  man. 

Symptoms. 

Torticollis  is  either  acute  or  chronic.  In  the  acute  form  the 
history  is  that  of  an  acute  muscular  rheumatism  with  some  con- 
stitutional disturbance  and  sudden  onset,  a  great  deal  of  pain  on 
movement  of  the  head,  and  the  head  is  held  to  one  side. 

The  acute  stage,  however,  lasts  but  a  short  time,  and  in  general 
it  may  be  said  that  pain  in  wry  neck  is  not  a  permanent  symptom. 
The  chief  discomfort  from  wry  neck  is  the  disfigurement  which  is 
always  noticeable  and  never  to  be  concealed.  There  may  be  pain 
in  the  neighborhood  of  the  affected  muscles   and  their  insertions. 

Palpation  usually  discloses  considerable  tenderness.  The  posi- 
tion assumed  by  the  head  is  more  or  less  typical  and  is  described 
farther  on. 

The  chronic  form  may  develop  from  the  acute  form.  It  may 
be,  as  has  been  said,  a  congenital  distortion,  or  it  maybe  of  gradual 
development  from  no  known  cause. 

The  position  held  by  the  head  varies  necessarily  with  the  mus- 
cles affected.  Where  the  sterno-cleido-mastoid  is  attacked,  the 
ear  of  the  affected  side  is  brought  near  to  the  sternum  and  the 
face    slightly   rotated    to    the    opposite  side.     If  the  trapezius  or 


TOA'T/CO/JJS. 


C>97 


posterior  muscles  arc  also  affected,  llie  Iiead  will  also  be  drawn 
back,  the  chin  elevated  above  its  normal  level,  and  the  features 
on  the  side  of  the  spasm  are  drawn  below  those  on  the  opposite 
side.  In  severe  and  especially  in  persistent  cases  the  jaw  is  rotated 
so  that  the  teeth  cannot  be  approximated.  In  proportion  to  the 
extent  the  trapezius  is  involved,  the  head  is  drawn  toward  the 
shoulder.  While  in  proportion  to  the  extent  which  the  spasm  in- 
volves the  sterno-mastoid  alone,  rotation  and  elevation  of  the  chin 
predominate.  In  addition  to  these  muscles  the  platysma,  scaleni, 
splenei,  and  other  deep  muscles  of  the  neck  arc  sometimes  affected 
and  modify  more  or  less  the  position   of  the  head.     The  attitude 


Fig.  688.— Wry  Neck  in  Adult. 


Fig.  689. — Wry  Neck  with  Marked  Contraction 

of  the  Sterno-Cleido-Mastoid  ^Muscle. 


is  sometimes  so  peculiar  as  to  render  it  dif^cult  to  determine  ex- 
actly what  muscles  are  affected. 

On  palpation  certain  muscles  will  be  found  to  be  hard  to  the 
touch  and  others  flaccid ;  no  pain  is  felt,  but  any  attempt  to  rectif}' 
the  head  may  cause  pain  if  persisted  in. 

Rotation  of  the  head  is  free  up  to  a  certain  limit,  varying  in 
extent.  It  is  not  possible  to  move  the  head  in  a  direction  against 
the  spasm,  and  a  persistent  effort  may  cause  considerable  pain. 
But  in  old  torticollis  pain  is  absent  and  only  the  tough  contraction 
restricts  the  mobility.  In  the  opposite  direction,  motion  is  greatly 
hmited,  and  is  often  possible  only  by  slow  and  careful  manipula- 
tion. Tenderness  over  and  around  the  affected  muscles  sometimes 
exists.  As  a  rule,  however,  in  the  chronic  affection,  pain  and  ten- 
derness are  absent. 

A  deviation  of  the  spinal  column  and  a  lateral  curvature  with 
rotation  necessarily  follow  torticollis  and  may  materially  add  to 
the  patient's  discomfort.     In  order  to  retain  the  head  in  a  vertical 


698 


ORTHOPEDIC  SURGERY. 


position,  the  patient,  unable  to  twist  the  cervical  spinal  column, 
will  twist  the  trunk,  leaving  one  shoulder  leaning  to  the  side. 
This  is  accompanied  by  a  complete  rotation  of  the  vertebrae  and 
projection  of  the  ribs  backward  on  the  convexity  of  the  lateral 
curve,  precisely  as  is  seen  in  the  compensating  curves  of  any 
marked  lateral  curvature.  Although  the  head  is  twisted,  strabis- 
mus rarely  results  except  in  cases  of  true  ocular  torticollis  already 
mentioned.  Although  the  movement  of  the  larynx  in  extreme 
cases  is  apparently  limited  by  the  distortion,  speech  is  not  affected, 

though  the  voice  in  singing, 
according  to  Couillard-La- 
bonnote,  becomes  modified 
by  the  development  of  this 
distortion.  A  slight  altera- 
tion of  surface  temperature 
has  been  observed,  being 
lower  on  the  affected  side. 

The  intermittent   form  of 
torticollis  is  much  less  com- 


FiG.  690. — View  of  the  Back  witb  a  Difference  in  the  Scapulas  Fig.  691.— Spasmodic  Wry  Neck, 

and  Rotation  of  the  Spine  Following  TorticoUis.  (Gowers.) 

mon  and  has  never  been  noted  in  children.  In  the  cases  observed  by 
the  writers  it  Avas  due  to  the  disturbance  of  the  nervous  system 
from  overwork,  from  anxiety,  and  in  two  cases  it  was  due  to  lead 
poisoning.  Of  the  four  cases  observed,  three  were  women.  Apart 
from  this  affection  the  patients  were  in  fair  health.  At  times  the 
head  could  be  held  in  a  proper  position,  but  locomotion  or  any 
excitement  or  the  apprehension  of  being  observed  would  produce 
such  a  contraction  of  the  head  that  it  would  be  twisted  violently 
to  one  side  and  rotated  to  an  extreme  limit.  A  slight  pressure  of 
the  hand  steadying  the  head  would  ordinarily  correct  it,  but  where 


Toimcojj.is. 


699 


the  muscular  contraction  became  excited,  great  force  was  required 
to  hold  it  in  place.  In  a  recumbent  position,  the  contraction  did 
not  take  place  ordinarily.  In  a  few  cases  it  has  been  observed  to 
be  of  malarial  origin,  yielding  to  quinine,  and  in  one  case  the 
spasm  was  brought  on  by  eating.  It  usually  disappears  during 
sleep.  The  spasm  is  sometimes  tonic  and  sometimes  clonic,  and 
sometimes  pain  is  excited  by  the  muscular  contraction.  It  is  usu- 
ally confined  to  the  muscles  of  one  side,  forming  what  Trousseau 
has  termed  tic  giratoire.  In  one  instance  reported  by  Studel,  the 
muscular  cramp  alternated  between  the  muscles  of  the  left  side 
and  that  of  the  right,  constituting  a  veritable  chorea. 

This  form  usually  begins  later  in   life;  it   may  be   unilateral  or 
bilateral. 

Slight  twitchings  of  the  muscles  are  sometimes  observed  for 
some  time  previous  to  an  outbreak  of  the  spasmodic  condition. 

A  variety  of  torticollis  has  been  described  by  Dally  as  occipito- 
atloidian.  It  is  characterized  as  follows:  The  development  is  usu- 
ally due  to  rheumatism,  and  it  is  characterized  anatomically  by  a 
subluxation  of  the  atlas  on  the  occipital  bone  in  such  a  way  that 
the  lateral  masses  are  transverse  to  the  vertical  plane.  Clinically, 
there  is  a  projection  of  the  transverse  process  posteriori}-,  so  that 
the  transverse  process  approaches  the  pharynx,  as  can  be  deter- 
mined by  the  finger.  There  is  a  spiral  torsion  of  the  head  which 
may  resemble  muscular  torticollis.  This  is  an  after-result  of  a  bony 
ankylosis. 

Diagnosis. 

There  is  no  difificulty  in  recognizing  the  deformity  called  wry 
neck.  The  head  is  twisted  to  one  side,  the  chin  being  to  the  right  or 
left  of  the  sterno-clavicular  notch, while  the  face  is  turned  to  one  side 
and  partly  upward.  The  shoulders  are  held  obliquely  to  the  trunk, 
twisted,  in  order  as  far  as  possible  to  bring  the  face  in  a  vertical 
line.  Certain  of  the  muscles,  frequently  the  sterno-cleido-mastoid, 
are  felt  hard  on  palpation,  and  some  rotation  of  the  head  is  possi- 
ble in  the  atlanto-axoid  articulation,  but  perfect,  free  rotation  of 
the  head  is  checked  by  the  contracted  muscles.  A  diagnosis  of 
the  cause  and  situation  of  wry  neck  is  more  difficult,  as  well  as  an 
attempt  to  distinguish  it  from  other  affections  which  give  rise  to  this 
malformation,  a  matter  which  is  of  great  importance.  Such  are 
disease  of* the  cervical  vertebra,  enlarged  cervical  glands,  cervical 
abscess,  and  stiff  neck  from  ordinary  cold. 

The  diagnosis  between  anterior  and  posterior  torticollis  (or  tor- 
ticollis  due   to    contraction    of    the    anterior    muscles,   chiefly  the 


700 


ORTHOPEDIC  SURGERY. 


sterno-cleido-mastoid,  and  that  due  to  the  contraction  of  the  pos- 
terior muscles,  the  trapezius  and  splenius  capitis,  etc.)  is  to  be 
based  on  palpation  chiefly. 

Palpation  also,  with  a  clinical  history  of  paralysis  and  the  evi- 
dence of  paralysis  elsewhere,  is  sufficient  usually  to  determine  the 
diagnosis  of  paralytic  torticollis. 

Torticollis  dependent  upon  enlarged  and  inflamed  glands  can 
usually  be  recognized  by  the  evidence  of  glandular  enlargement. 

There  is  ordinarily  little  difficulty  in  recognizing  the  common 
acute  wry  neck.  Its  course  is  acute,  the  deformity  appears  sud- 
denly, and  is  usually  accompanied  by  pain.  Improvement  is  to 
be  noticed  in  a  comparatively  short  time. 

For  a  diagnosis  of  torticollis  from  caries  of  the  spine,  the  reader 
is  referred  to  the  article  on  caries  of  the  spine,  but  in  general  it 
may  be  said  that  in  caries  there  is  greater  rigidity,  and  this  involves 
all  the  muscles  of  the  neck,  and  particularly  the  posterior  groups. 

The  pain  elicited  by  attempts  to  twist  the  head  is  greater.  There 
is  also  in  cervical  caries  a  facial  expression  of  anxiety,  a  slight,  fre- 
quent contraction  of  the  eyebrows,  which  is  not  seen  usually  in 
pure  torticollis.  When  a  patient  with  cervical  caries  attempts  to 
lie  down  or  turn  over  the  head  is  instinctively  steadied  with  the 
hand,  while  in  true  torticollis  this  is  not  so  constant  a  symptom. 

There  is  never  any  difficulty  in  distinguishing  anterior  torticollis 
from  wry  neck  due  to  caries  of  the  spine,  as  in  the  latter  the  sterno- 
mastoid  muscle  is  not  prominently  contracted,  but  it  is  sometimes 
impossible  to  determine  without  several  examinations  and  a  con- 
tinued observation  of  the  case  whether  posterior  torticollis  is  sec- 
ondary to  a  caries  or  idiopathic. 

It  maybe  said  that  in  all  cases  of  posterior  torticollis  caries 
must  be  suspected,  and  the  symptoms  of  cervical  caries — referred 
pain,  projection  of  the  vertebra,  stiffness  of  the  back — must  be 
carefully  and  positively  excluded  before  a  diagnosis  of  posterior 
torticollis  can  be  formed. 

Prognosis. 

The  acute  idiopathic  wry  neck  due  to  muscular  inflammation 
runs  a  short  course  and  tends  naturally  to  recovery,  though  in  a 
few  cases  it  may  become  chronic.  Torticollis  due  to  the  abscess 
of  cervical  glands  terminates  with  the  complete  discharge  of  the 
abscess  as  a  rule.  Intermittent  spasmodic  torticollis  m2.y  become 
cured  spontaneously,  or  may,  as  is  more  common,  remain  without 
change  for  m-any  years.  Congenital  forms  of  torticollis  and  the 
common  acquired  form  associated  with  muscular  contraction  which 


TORTICOIJJS. 


701 


has  become  chronic  and  developed  fibrous  muscular  degeneration 
are  of  course  incurable  without  surgical  interference.  Little  or  no 
constitutional  disturbance  follows  this  affection,  which  is  more  dis- 
tressing on  account  of  the  unsightliness  than  from  any  actual  dis- 
comfort. The  deaths  that  are  reported  as  following  torticollis 
have  been  in  a  few  instances  due  to  septicaemia  following  operation. 
The  deformity  is  one  which  is  eminently  curable  by  surgical 
intervention.  Complete  correction  and  permanent  cure  are  possible 
in  all  cases  except  in  the  intermittent  form,  which  is  dependent 
upon  a  general  depressed  state  of  the  nervous  system,  where  a 
cure  cannot  always  be  promised. 

Treatment. 

The  treatment  of  torticollis  depends  to  a  great  extent  on  the 
variety.  In  acute  torticollis  due  to  the  inflammation  of  the  mus- 
cles, the  treatment  is  largely  the  alleviation  of  the  symptoms. 
This  is  best  done  by  the  application  of  moist  heat  in  the  forms  of 
cataplasms  and  poultices,  the  inunction  of  oleate  of  atropia,  or 
morphia  to  relieve  the  pain,  or  the  subcutaneous  injections  of 
morphia.  Rest  of  the  head,  and  anti-febrile  constitutional  treat- 
ment are  of  course  advisable  where  there  is  any  fever.  Iodine, 
plasters,  and  counter-irritation  are  recommended  by  most  writers. 

The  treatment  of  ordinary  wry  neck  is  either  operative,  or  purely 
mechanical,  or  mechanical  and  operative. 

In  the  lighter  cases,  mechanical  treatment  and  the  wearing  of 
appliances  to  hold  the  head  in  a  correct  position  are  sometimes 
sufificient. 

Torticollis  due  to  cervical  caries  is  treated  according  to  the  prin- 
ciple of  treatment  of  cervical  caries,  and  will  disappear  with  the 
improvement  of  the  bone  disease.  Torticollis  due  to  muscular 
contraction  secondary  to  cervical  abscesses  or  enlarged  glands  is 
corrected  by  the  proper  treatment  of  cervical  abscess. 

Mechanical  Treatment. — Mechanical  treatment  without  the  aid 
of  operation  is  usually  unsuccessful,  except  in  the  lightest  cases. 
The  simplest  appliance  consists  in  a  chin  support,  such  as  has  been 
described  under  the  treatment  of  spinal  disease.  This  relieves  the 
muscles  of  the  weight  of  the  head  and  in  the  lightest  cases  will  aid 
the  establishment  of  natural  cure.  Such  treatment,  however,  is  of 
use  only  in  the  simplest  cases. 

Appliances  for  twisting  the  head  are  needed,  and  the  one  repre- 
sented in  the  accompanying  illustration  is  mechanicall}'  el^cient 
(Fig.  693). 

The  trunk  is  held  in  an  appliance  which  consists  of  a  steel  waist- 


702 


OR  THOPEDIC  S  UR  GER  V. 


band  a,  connected  with  a  steel  upright  d,  passing  up  the  back,  the 
whole  is  secured  by  means  of  shoulder  straps  c.  The  head  is  held 
in  a  padded  metal  cap  d,  which  is  secured  to  the  back  piece  by 
broken  uprights  jointed  with  screw  joints  {c,  f,  g)  armed  with  a 
key.  By  the  use  of  this  key  the  head,  held  in  the  metal  cap,  can 
be  turned  in  all  desired  directions,  ni  and  k  are  arrangements  by 
which  the  crutch  k  in  the  upright  b  can  be  raised. 

Cravats  of  various  forms  are  used  for  fixation  of  a  distorted 
head,  from  the  simple  or  Thomas  collar  used  in  caries  of  the  spine 
to  more  elaborate  appliances  with  adjustable  screws  indicated  in 


Fig.  692. 


Fig,  693. — Appliance  for  Mechanical  Twisting  of  the 
Head  in  Torticollis. 


the  accompanying  diagrams.     These,  however,  a^-e  more  efficacious 
after  operative  correction  than  in  treatment  without  operation. 

One  of  the  simplest  of  all  forms  of  appliance  is  that  used  by  Dr. 
Buckminster  Brown,  of  Boston.  A  wire  collar  passes  around  the 
neck  and  is  furnished  with  a  plate  under  the  chin,  arranged  so  as 
to  press  on  the  deflected  side  of  the  chin.  Pressure  is  also  ar- 
ranged to  be  applied  to  the  inclined  side  of  the  head  behind  the  ear. 
The  wire  collar  is  attached  to  a  ring  which  rests  upon  the  shoulder, 
and  in  the  back  this  is  furnished  with  an  arm  which  passes  down 
the  back.  Straps  are  fastened  to  this,  one  passes  around  the  trunk, 
and  another  around  the  shoulder  on  the  side  of  the  deflected  chin : 


TOK'l'JCOlJJS. 


703 


by  tightening  this  latter  strap  it  will   be  found  that  pressure  is  ex- 
erted on  the  chin  in  the  proper  direction. 

A  simpler  form  of  appliance  is  furnished  by  a  sLout  band  arc^und 


Fig.  694. — Stiffened  Cravat  for  Correcting 
Wry  Neck. 


Fig.  695. — Mechanical  Contrivance  for 
Correcting  Torticollis. 


the  thorax;  to  this  are  attached  hooks  at  desired  points,  the  waist- 
band being  lined  with  adhesive  plaster  to  prevent  slipping,  and  it 
may  be  kept  from  being  pulled  upward  by  means  of 
perineal  straps  (not  indicated  in  the  illustration).  The 
head  is  secured  by  means  of  bandages  which  are  fixed 
on  the  forehead  by  means  of  a  strip  of  adhesive  plaster, 
to  which  the  bandage  is  sewn.     A  strap  is  fastened  to 


Fig.  696. — Screw  Appliance  for  Correcting  Torticollis 


Fig.  697.  — Buckminster  F!ro\vn"s  Wire 
Collar  for  Plolding  Head. 


the  bandage  behind  the  ear,  and  at  the  lower  part  fastened  to  a 
chain  which  can  be  hooked  into  the  hooks  on  the  chest  bands; 
several  straps  are  usually  required,  according  to  the  distortion. 


704 


ORTHOPEDIC  SURGERY. 


The  same  principle  can  be  applied,  but  less  efficiently,  by  means 
of  elastic  straps  passing  from  the  head  band  to  the  axilla. 

Correction  can  be  efficiently  used  in  many  cases  by  keeping  the 


Fig.  698.  Fig.  699. 

Figs.  698,  699. — Appliances  for  the   Mechanical  Correction  of  Wry  Neck,  Depending  upon  Traction 

from  the  Thorax  or  Axilla. 

patient  in  a  recumbent  position.  Adhesive  plaster  and  bandages 
should  be  applied  to  the  head,  and  to  the  end  of  the  bandages 
weights    can  be  attached    so    as    to    exercise    traction  in    various 


Fig.  700.— Side  Traction  'by  Means  of  Adhesive  Plaster  Bandages  and  Weight  for  Twisting  the 

Head  in  Torticollis. 

directions,  pulling  the  head  to  one  side,  rotating  it  and  turning  the 
chin  in  the  desired  direction. 

The  method  is  indicated  in  the  accompanying  picture  (Fig.  700). 


IVRTICOLUS. 


705 


The  patient  is  secured  to  a  bed  frame  such  as  is  employed  in  caries 
of  the  spine,  and  the  shoulders  are  fixed  by  straps.  Sand  bags  can 
be  placed  at   the   sides  of  the   head,  but  are  xmA  as  a  rule  needed. 


1  1-^^.   B  -/ 


Fig.  701. — Posterior  Torticollis  Before  Forcible 
Straightening. 


Fig.  702. — Result  After  Operation. 


This  method  of  correction  is  a  tedious  one,  but  it  can  be  applied  at 
night  and  supplemented  in  daytime  by  a  mechanical  appliance. 

Op cr at i %> e  Treatment. — M e- 
chan'cal  treatment  alone  is  rarely 
successful,  though  it  is  of  great 
assistance  as  an  aid  to  the  cor- 
rection of  the  deformity. 

The  operative  procedures  are 
tenotomy  and  open  incision. 

Tenotomy  is  applicable  to  con- 
traction of  the  sterno-cleido-mas- 
toid  muscle. 

The  place  of  election  for  di- 
vision of  the  sterno-mastoid  is  in 
its  lower  part.  In  its  upper  part 
it  is  more  or  less  surrounded  with 
nerve  filaments.  A  strong  teno- 
tome is  selected,  the  skin  is 
pulled  down  and  the  tenotome  is 
inserted  through  the  skin  and  over  the  clavicle.  The  skin  is  then 
allowed  to  slip  up  and  the  tenotome,  which  has  been  inserted  in 
45 


Fig.  703. — Brown's  Apparatus  Applied. 


7o6 


ORTHOPEDIC  SURGERY. 


the  skin,  moves  with  it  and  should  lie  half  an  inch  to  an  inch  above 
the  clavicle.  Care  should  have  been  taken  to  avoid  the  external 
jugular  vein  which  is  readily  seen  or  made  apparent  by  pressure 
and  distention  of  the  vein.  The  blade  of  the  tenotome  is  then 
passed  underneath  the  contracting  muscle  and  its  sheath,  its  cutting 
edge  is  then  turned  toward  the  skin  and  by  a  careful  sawing  mo- 
tion the  tendon  is  felt  to  give  way;  it  being  essential  that  all  of 
the  contracting  tissue  be  divided  and  that  the  muscle  be  not  simply 
transfixed.     After  this  the  head  should  be  fixed. 

DiefTenbach  operates  on  the  left  side  m  the  way  just  described. 
On  the  right  he  inserts  the  knife  between  the  trachea  and  outer  por- 
tion of  the  muscle  and  divides  the  anterior  part,  and  then  the  pos- 
terior if  necessary.  Some  surgeons  pass  the  tenotome  under  the 
skin  and  cut  downward,  others  pass  the  tenotome  beneath  the 
skin  and  cut  upward.  The  danger  of  the  latter  procedure  is  in- 
complete division;  and  that  of  the  former  operation  of  dividing 
the  vessels.  The  superficial  veins  are  to  be  avoided  by  careful  in- 
spection before  introduction  of  the  tenotome. 

The  head  should  not  be  returned  to  the  position  of  deformity 
after  division  of  the  tendons  as  is  recommended  by  some  sur- 
geons, and  should  be  immediately  rectified  and  retained  in  a  cor- 
rected position,  either  by  means  of  appliances  figured  or  by  the 
use  of  a  plaster-of-Paris  bandage  inclosing  the  head  and  trunk. 
The  writers  prefer  after  operation,  if  much  resistance  is  encoun- 
tered, to  place  the  patient  in  bed  secured  to  the  bed  frame  described 
in  the  treatment  of  caries  of  the  spine,  and  to  apply  straps  and 
weights  already  mentioned  as  a  means  of  correction.  This  can  be 
employed  for  a  week  or  ten  days  and  a  light  retention  appliance 
be  used,  that  of  Buckminster  Brown  being  found  simple  and  con- 
venient. 

Open  Incision. — It  will  be  found  practically  impossible  in  some 
cases  to  entirely  divide  with  the  tenotome  all  the  deeper  contracted 
fibres,  and  much  will  have  to  be  left  to  mechanical  stretching.  For 
this  reason  an  open  incision  is  more  thorough,  and  if  done  with 
aseptic  and  antiseptic  precautions,  thus  avoiding  the  danger  of 
suppuration,  offers  the  best  means  of  correction. 

If  an  open  incision  of  the  sterno-mastoid  is  undertaken,  the  ordi- 
nary precautions  of  aseptic  surgery  should  be  thoroughly  carried 
out,  and  an  incision  parallel  to  the  clavicle  and  an  inch  above  it 
should  be  made  reaching  across  the  contracting  muscle,  a  director 
should  be  passed  under  the  muscles  and  fascia,  and  the  whole 
divided  with  care.  After  this  is  done,  the  skin  should  be  sewn  up 
and  the  head  fixed.  The  head  should  be  kept  in  an  over-corrected 
position,  either  by  plaster  bandage  or  by  some  mechanical  means. 


TOin  ICOLLIS.  707 

until  union  of  the  divided  structures  has  taken  place.  The  most 
convenient  arran^^einent  will  be  found  to  be  the  correcting  arrange- 
ment already  mentioned  by  means  of  straps  and  weights,  followed 
in  ten  days  or  a  fortnight  by  the  Buckminster  ]kown  head  support. 

This  latter  should  be  worn  for  three  to  six  months,  when  perma- 
nent cure  will  be  established. 

The  advantages  of  a  tenotomy  are  two.  There  is  less  danger  of 
suppuration  and  no  scar  of  the  skin  is  left.  The  disadvantages  are 
that  it  is  almost  impossible,  as  has  been  said,  in  some  instances  to 
thoroughly  divide  the  muscle  and  the  deeper  contracted  fasciae 
with  accuracy  by  a  simple  tenotomy.  In  all  severe  cases  a  direct 
open  incision  is  preferable.  It  allows  the  operator  the  more  bold 
and  intelligent  use  of  the  knife.  The  cicatrix  from  an  open  incision 
is  larger  than  after  tenotomy,  although  by  adherence  to  asepsis  one 
maybe  reasonably  sure  of  union  by  first  intention. 

Both  after  tenotomy  or  after  open  incision  there  is  danger  of 
wounding  the  internal  jugular;  deaths  from  this  cause  have  been 
reported  after  tenotomy. 

The  writers  would  record  one  case  where  the  internal  jugular 
was  wounded  in  an  op'en  incision.  It  Avas  tied  and  no  untoward 
results  followed,  the  patient  made  a  perfect  recovery.  The  vein 
lies  under  the  deep  fascia,  but  it  can  be  avoided  in  open  incision  if 
the  neck  be  not  stretched  and  care  be  taken  not  to  open  the  deep 
cervical  fascia. 

The  results  of  correction  of  torticollis  by  tenotomy  or  by  open 
division  are  extremely  satisfactory.  The  pictures  (Figs.  704,  705) 
show  the  results  in  open  incision  of  the  sterno-cleido-mastoid  in 
two  cases  of  torticollis.  The  illustrations  are  reproduced  from 
photographs  taken  one  month  in  the  first  case,  and  in  the  second 
one  year  after  the  operation.  The  cases  were  nine  and  fifteen 
years  old  respectively  and  the  deformity  before  operation  was  in 
both  cases  severe,  and  of  long  standing. 

After  the  operation  the  patients  were  in  each  case  kept  in  bed 
for  ten  days,  and  a  wire  collar  was  applied  supporting  the  head  in 
a  normal  position.  In  the  older  of  these  cases  the  support  was 
only  worn  six  months.  The  deviation  of  the  eyebrows  and  eyes 
from  the  position  at  right  angles  with  the  axis  of  the  face  due  to 
the  long  continuance  of  the  distortion  had  in  the  year  following 
correction  diminished  but  still  remained. 

Beside  the  deformity  largely  associated  with  contraction  of  the 
sterno-mastoid  muscle — anterior  torticollis — another  form,  as  has 
been  already  mentioned,  is  seen,  viz.,  posterior  torticollis.  This 
variety,  which  is  described  chiefly  by  Delore,  constitutes  a  class  of 
obstinate  cases.     The  only  efificacious  treatment  is  that  of  forcible 


7o8 


ORTHOPEDIC  SURGERY. 


correction  without   tenotomy,  for   the  reason  that,  as  a  rule,   the 
muscles  are  too  deep  or  extensive  to  be  tenotomized.     The  writers 

have  divided  the  outer  bands  of 
the  anterior  scalenus  and  trape- 
zius by  open  incision  and  can  re- 
port the  feasibility  of  the  proced- 
ure. In  correcting  this  deformity 
the  patient  should  be  thorough- 
ly anaesthetized  and  an  assistant 
should  firmly  hold  the  shoulders, 
while  the  patient  should  be  drawn 
so  that  the  head  projects  beyond 
the  end  of  the  operating  table. 
The  head  should  be  held  by  the 
hands  of  the  surgeon  and  rotated 
in  all  directions,  considerable  force 
being  used.  The  danger  of  frac- 
turing the  spine  is  in  such  cases 
of  course  so  slight  as  to  be  disre- 

Result  of  Open  Incision  and  Correction    gardcd,   and  the  deformity  Can    be 

over-corrected.  After  the  opera- 
be  retained  in  some  retaining  appliance, 
or    silicate-of-potash    bandages    or   in    the 


Fig. 


in  a  Girl  of  Eight,  One  Month  After  Operation. 

tion  the  head  should 
either  plaster-of-Paris 
arrangement  already 
described. 

After  the  head  has 
been  over -corrected 
and  fixed  in  an  over- 
corrected  position  in 
this  way,  a  retaining 
appliance  should  be 
used. 

Many 
surgeons 


orthopedic 

advise  the 
use  of  correcting  ap- 
pliances after  tenot- 
omy or  operation,  to 
complete  the  correc- 
tion. It  is  the  opinion 
of     the    writers     that 

,  ,  .  .  Fig.  705. — Result  of  Open  Incision  One  Year  After  Correction  in 

where     the     patient      is   a  Case  of  Torticollis  in  a  Girl  Si.xteen  Years  Old,  Showing  Incidentally 
under     an      ariPPSthetic      the  Unequal  Development  of  the  Face. 

complete  correction  or  over-correction  after  tenotomy  is  a  method 
which  saves  the  patient  suffering  and  gives  the  best  results. 


rOh'TfCOTJJS. 


709 


The  treatment  of  tliese  two  forms  of  torticollis  may  be  summa- 
rized as  follows :  Anterior  variety :  division  either  by  tenotomy  or 
open  incision  of  such  muscular  bands  or  fibres  as  are  within  the 
reach  of  the  knife.  Posterior  variety :  manual  correction  and  over- 
correction of  the  deformity  under  an  an;esthetic.  Fixation  of  the 
head  in  an  over-corrected  position  and  the  subserpient  wearing  of 
retentive  appliances. 

Intermittent  Tortieollis. — The  treatment  of  intermittent  torticollis 
is  chiefly  mechanical  and  constitutional.  The  latter  will  include 
tonics,  gymnastics  of  the  affected  muscles,  and  electricity.  These 
cases  are  largely  due  to  a  depressed  nervous  condition^ — a  condition 
which  is  aggravated  by  the  patient's  anxiety  to  avoid  a  noticeable 
ciistortion  when  in  public.  If  proper  retentive  appliances  are  used 
and  the  patient's  anxiety  relieved  by  the  prevention  of  a  distorted 
attitude,  a  good  deal  is  gained  by  the  relief  of  the  patient's  anxiety. 
In  some  instances,  however,  the  muscular  spasms  are  so  strong 
that  very  heavy  appliances  are  necessary.  Constitutional  treat- 
ment in  the  way  of  tonics,  change  of  scenery  and  air,  and  rest  from 
occupation  are  of  great  help.  In  some  instances  of  clonic  torti- 
collis there  is  a  spontaneous  cure,  but  with  these  exceptions  torti- 
collis is  an  affection  which  becomes  persistent,  and  unless  corrected 
becomes  a  permanent  deformity. 

Galvanism  to  the  affected  muscles  apparently  is  of  benefit  in  a 
certain  number  of  cases.  These  are  almost  without  exception  of 
the  clonic  form,  and  in  patients  whose  system  has  been  overtaxed, 
and  attention  to  the  health  is  of  fully  as  great  importance.  Some 
writers  have  denied  the  advantage  of  electricity  in  any  case,  but 
the  statement  is  too  strong.  In  a  few  cases,  which  were  apparently 
due  to  faulty  antagonism,  faradization  to  the  muscles  of  the  op- 
posite side  resulted  in  a  cure. 

In  a  certain  number  of  cases  surgery  directed  to  the  nerve  will 
be  found  to  be  necessary.  Tenotomy,  or  free  division  of  the  mus- 
cles in  these  cases  of  clonic  spasm  has  in  a  few  instances  afforded 
relief,  but  the  results  are  not  as  a  rule  satisfactory,  and  in  these 
severe  cases  the  general  health  suffers  so  much  that  radical  mea- 
sures are  indicated.  There  are  three  courses  open :  nerve  stretch- 
ing, nerve  division,  and  nerve  resection.  The  advisability  of  the 
first  is  doubtful.  It  has  been  done  a  few  times,  and  the  results  are 
not  encouraging,  and  probably  in  all  cases  severe  enough  to  require 
surgical  treatment  of  the  nerve,  more  definite  measures  than 
stretching  will  be  necessary  to  put  an  end  to  the  irritative  con- 
dition. 

Reeves  has  in   five  cases  stretched  or  excised  portions  of  the 


7 JO  ORTHOPEDIC  SURGERY. 

spinal  accessory,  but  without  much  success.  Richardson  reports 
one  case  in  which  there  was  some  benefit.  Hanson  reports  curing 
•two  cases  by  nerve  stretching. 

A  convenient  situation  for  reaching  the  spinal  accessory  nerve  is 
along  the  anterior  border  of  the  sterno-mastoid  muscle.  The  nerve 
enters  the  muscle  about  an  inch  and  a  half  below  the  mastoid  pro- 
cess, and  can  be  found  here.  By  an  incision  in  this  situation, 
Richardson  advises  scratching  the  tissues  in  the  bottom  of  the 
wound  with  a  director,  by  which  the  nerve  is  irritated,  thus  caus- 
ing a  contraction  of  the  muscle,  and  this  serves  as  an  aid  in  finding 
the  nerve. 

For  finding  the  nerve,  the  following  methods  may  be  found  of 
value  : 

An  incision  three  to  four  inches  long  should  be  made  close  to 
the  posterior  border  of  the  muscle,  commencing  a  little  above  the 
upper  horizontal  line  and  ending  just  below  the  lower.  The  trans- 
verse cervical  nerve  may  be  seen  and  should  be  laterally  displaced. 
The  cervical  fissure  should  be  open  and  when  the  posterior  border 
of  the  sterno-mastoid  is  seen,  this  should  be  lifted  up  and  forward 
and  the  nerve  will  be  found  piercing  it  (Reeves). 

Annandale  operates  by  an  incision  three  inches  long,  beginning 
at  the  lower  border  of  the  mastoid  process,  along  the  anterior 
border  of  the  sterno-mastoid.  Southam  has  reported  cases  of 
stretching,  in  which  he  opened  the  posterior  triangle,  through  an 
incision  two  inches  in  length,  along  the  posterior  border  of  the 
muscle,  with  the  centre  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage.  The  nerve  was  found  beneath  the  fascia,  run- 
ning obliquely  downward  and  outward,  to  terminate  in  the  trape- 
zius. This  site  has  been  advised  for  finding  the  nerve  for  resection 
or  division,  but  must  be  followed  up  toward  its  origin. 

If  two  horizontal  lines  be  drawn,  the  upper  passing  downward 
from  the  angle  of  the  jaw,  the  lower  from  the  border  of  the  thy- 
roid cartilage,  they  will  form  with  the  anterior  and  posterior  bor- 
der of  the  sterno-mastoid  a  parallelogram,  of  Avhich  the  spinal  ac- 
cessory forms  a  diagonal  running  from  the  upper  angle  of  this 
parallelogram  to  the  lower  and  outer  one. 

After  exposure  of  the  nerve  it  may  be  simply  divided,  or  a  por- 
tion resected — the  two  methods  having  no  particular  claims  for 
performance  except  that  of  thoroughness.  If  it  is  thought  that 
the  cessation  of  the  spasmodic  condition  for  a  while  will  be  suffi- 
cient to  effect  a  cure,  the  nerve  may  be  simply  divided  with  the 
hope  that  there  may  be  reunion  later  with  restoration  of  function, 
but  too  great  reliance  should  not  be  placed  on  this.     In  any  case, 


TOA'T/CO/JJS.  711 

where  the  origin  i'S  supposed  to  he  central,  resection   h;ul  better  be 
resorted  to  at  once. 

After  either  of  the  two  operations,  the  mastoid  and  sometimes 
the  upper  portion  of  the  trapezius  will  be  found  flabby,  and  volun- 
tary power  of  them  will  be  lost.  The  deformity  in  consequence 
of  this  loss  of  power' is  usually  not  great. 


CHAPTER  XXII. 
UNILATERAL   ATROPHY   AND    HYPERTROPHY. 

Etiology  and  Occurrence. 

Cases  of  unilateral  difference  in  the  growth  of  the  body  have 
recently  attracted  considerable  attention  chiefly  because  of  their 
obscure  etiology. 

Hunt/  of  Philadelphia,  in  1879,  made  observations  which  led  him 
to  state  that  bilateral  symmetry  as  to  the  length  of  the  lower  limbs 
was  exceptional.  Since  then  several  observers  have  corroborated 
the  views  of  Hunt.  Dr.  Cox'  measured  the  lower  limbs  in  fifty-four 
healthy  persons,  and  in  only  six  were  the  limbs  of  the  same  length. 
There  was  no  uniformity  with  regard  to  which  side  was  the  longer. 
The  variation  in  length  was  from  one-eighth  to  seven-eighths  of  an 
inch.  Wight  3  gives  the  measurements  of  sixty  persons,  and  con- 
cludes "that  the  greater  number  of  limbs,  comparing  the  limbs  of 
the  same  person,  show  a  difference  in  length.  About  one  person 
in  every  five  has  limbs  of  the  same  length."  The  difference  is 
usually  from  one-eighth  of  an  inch  to  an  inch.  In  one  case  the 
difference  was  as  great  as  one  and  three-eighths  inches. 

Mr.  Callender''  has  measured  forty  individuals,  and  found  the 
limbs  of  equal  length  in  all  but  two,  in  whom  the  variation  was 
slight.  He  used  a  simple  tape — all  the  persons  measured  happened 
to  be  Englishmen.  Roberts  ^  and  Dwight*  have  attempted  to  set- 
tle the  question  by  observation  on  the  bones  of  skeletons.  Roberts 
found  asymmetry  the  rule  in  femora  and  tibiae  in  eight  skeletons. 

Dwight  reports  measurements  in  eleven  skeletons;  in  five  the 
femora  were  equal ;  in  one  case  the  difference  was  three-quarters 
of  an  inch.     Tibiae  were  equal  in  only  two  cases.     In  some  cases 

^  Am.  Journal  Med.  Sciences,  Jan.  1S79. 

^  Am.  Journal  Med.  Sciences,  April,  1875. 

3  Archives  Clin.  Surg.,  vol.  i.,  No.  S,  Feb.,  1877. 

''  St.  Bartholomew's  Hospital  Reports,  vol.  xiv.,  1878,  p.  187 

5  Philadelphia  Med.  Times,  August  3d,  1878. 

*  Mass.  Med.  Soc.  Communications,  1878.  p.  175. 


UNI  LATER  A  [.   A'/A'O /'//)'   AND   1 1  V  P  I'-KTROI'l  I  Y.  713 

the  lon<^cr  femora  <ind  tibi;e  were  on  the  same  side,  and  in  some 
cases  on  different  sides.  Dr.  J.  (Larson,  of  London,'  published  the 
residts  of  the  measurements  of  seventy  skeletons.  The  lower  limbs 
were  equal,  he  says,  in  only  ten  per  cent. 

Morton  "^  has  made  many  measurements  and  found  that  among 
513  boys  272  presented  inequality  in  the  length  of  the  lower  limbs 
varying  from  one-eighth  of  an  inch  to  one  inch  and  five-eighths. 
In  241  there  was  no  appreciable  difference  in  length.  In  none  of 
these  cases  had  there  been  previous  fracture  or  any  bone  or  joint 
disease  which  might  have  accounted  for  the  defect.  Three  of  the 
boys,  including  those  that  exhibited  the  greatest  shortening,  were 
aware  of  the  fact  that  one  limb  was  deficient  in  length.  BurreP 
reported  three  cases  of  marked  unilateral  atrophy  only  noticed 
when  the  children  began  to  walk,  when  it  became  manifest  by  a  Hmp. 

Broca-t  relates  the  case  of  a  boy  of  eleven  who  appeared  "as  if 
the  two  halves  of  the  body  were  different-sized  persons  joined 
together." 

Sir  James  Paget  ^  finds  that  there  is  often  a  difference  of  volume 
as  marked  as  is  the  difference  in  length,  and  it  is  often  difficult  to 
say  which  of  the  two  unequal  limbs  is  the  better  or  the  more  ap- 
propriate to  the  other  parts  of  the  body. 

It  must  be  admitted  that  the  conclusions  reached  by  all  have 
been  nearly  identical,  namely,  that  throughout  the  long  bones  of 
both  extremities  there  exists  often  a  certain  amount  of  asym- 
metry in  regard  to  length. 

The  very  important  theoretical  and  practical  bearing  of  this  is 
easily  seen.  The  relation  that  short  limbs  may  bear  to  cases  of 
lateral  curvature'  is  discussed  in  Chapter  II.  In  Hartwig's  studies 
of  the  upper  extremity  the  bones  of  the  right  arm  were  found 
to  be  the  longest,  corresponding  with  Hyrtl's  results.  Poncef 
has  recently  reported  a  case  of  alternate  inequality,  the  right  arm 
and  the  left  leg  being  better  developed. 

The  progressive  facial  hemiatrophy  is  of  interest  from  an  etio- 
logical standpoint. 

The  etiology  of  these  different  forms  of  atrophy  is  obscure.  In 
the  cases  of  injury  to  the  joints  Nicoladoni  has  suggested  a  pre- 
mature synostosis  of  the  epiphyseal  cartilages.  The  facial  hemi- 
atrophy is  thought  to  be  a  trophic  neurosis  of  certain  nerve  ganglia 

^  Journal  of  Anat.  and  Physiology,  vol.  xiii.,  p.  502,  1879  ;    Nature,  Jan.  26th,  1884. 

-  "Asymmentry  of  the  Lower  Limbs,"  etc.,  Phila.  Med.  Times,  July  loth,  1SS6. 

3  Boston  Med.  and  Surg.  Journal,  vol.  cvi.,  p.  462. 

■♦  Canstatt's  Jahresbericht,  1S59,  vol.  iv.,  p.  6. 

=  Am.  Journal  Med.  Sciences,  Januarv,  iS£6. 

^  Revue  de  Chirurgie,  April  loth,  1SS8. 

7  Lyon  jMedical,  January,  2gth,  18S8. 


714 


ORTHOPEDIC  SURGERY. 


or  nerves — or  a  simple  vascular  disturbance  of  the  part  has  been 
suggested  as  a  possible  cause. 

It  is  probable  that  certain  of  these  cases  are  the  result  of  a  slight 
former  hemiplegia,  which  has  manifested  itself  chiefly  in  retarding 
the  growth  of  the  affected  side  without  any  distinct  loss  of  motor 
power.  This  seemed  probable  in  a  case  recently  seen  by  the 
writers,  where  the  right  side  of  the  body  was  distinctly  behind 
the  left  side  in  growth,  but  the  left  side  of  the  head  was  smaller 
than  the  right  side — a  relation  which  suggested  most  strongly  the 
existence  of  some  lesion  of  the  trophic  centres  in  the  left  cerebral 
hemisphere. 

Syviptoms  and  Ti'eatincht. — Long  continued  slight  and  oftentimes 
severe  backaches,  with  lumbar  and  pelvic  pain,  involving  the  dis- 
tribution of  the  sciatic  nerve,  are  often  due  to  asymmetry  of  the 
lower  limbs.  Such  symptoms  are  at  once  relieved  upon  correcting 
the  asymmetry.  A  person  in  previous  good  health  may  from  some 
depressing  physical  condition  begin  to  have  the  above  symptoms 
of  pain  localized  as  stated,  and  upon  examination,  unequal  limbs 
will  be  found  in  very  many  cases. 

Morton  says  that  U.  S.  pension  examining  surgeons  state  that 
many  applications  for  pension  have  been  made  for  disabilities  de- 
scribed as  lumbago,  supposed  to  have  been  caused  by  exposure,  or 
from  injuries  contracted  during  the  war  for  the  union.  In  nearly 
all  such  cases,  an  examination  has  revealed  a  previously  unrecog- 
nized asymmetry,  and  that  the  symptoms  were  probably  induced 
by  this  defect  in  development. 

Symptoms  of  inequality  of  the  lower  limbs  may  simulate  coxalgia. 
In  such  cases  the  legs  should  of  course  be  measured.  Children 
complaining  of  backache,  or  'so-called  growing  pains,  should  be 
carefully  examined  for  any  such  anatomical  defects. 

The  medico-legal  bearing  of  the  fact  of  asymmetry  has  been 
called  attention  to  by  Dr.  Hunt  in  the  paper  already  referred  to. 

Hypertrophy  of  the  limbs  may  occur  from  two  causes,  disease 
of  the  vessels  or  from  a  congenital  tendency  similar  to  that  which 
produces  hypertrophy,  called  congenital  tumors. 

Striimpel  suggests  a  neuropathic  disturbance  as  a  possible  cause 
of  a  unilateral  hypertrophy  which  is  rarely  met  with,  but  cites  a 
case  of  a  boy  ten  years  old,  otherwise  healthy,  in  whom  there  was  a 
marked  hypertrophy  of  the  left  side  of  his  face  and  left  arm,  grad- 
ually developing.  The  congenital  hypertrophy  of  the  fingers  al- 
luded to  in  Chapter  XV.  is  commonly  unilateral. 


CHAPTER  XXIII. 
DUPUYTREN'S   CONTRACTION   OF   THE    FINGERS. 

Definition. — History.—  Pathology. — Etiology   and    Occurrence. — Symptoms. — 
Diagnosis. — Prognosis. — Treatment. 

Dupuytren'S  contraction  i.s  the  term  applied  to  a  permanent 
flexion  of  one  or  more  fingers,  which  is  due  to  a  retraction  of  the 
pahnar  fascia  and  its  digital  prolongations. 

There  is  no  other  English  name  by  which  the  affection  is  known 
unless  the  term  contraction  of  the  palmar  fascia  be  employed.  The 
French  speak  of  it  as  La  Contraction  des  Doigts  (Dupuytren)  or 
La  Maladie  de  Dupuytren.  The  German  equivalent  is  Die  Dupuy- 
tren'sche  Contractur  der  Finger. 

History. 

A  case  of  this  affection  was  clearly  described  by  Plater  ("  Obser- 
vationum  D."  Liber  I.,  p.  140,  1610),  who  considered  it  due  to  con- 
traction of  the  tendons.  The  next  observation  seems  to  have  been 
made  by  Chomel '  in  1813;  Boyer,""  d'Alibert,^  Henry  Cline,  Astley 
Cooper,  and  other  writers  described  cases  and  speculated  upon  its 
pathology,  but  it  was  Dupuytren  who  first  called  attention  to  it  in 
such  a  way  that  the  medical  world  was  compelled  to  listen.  He 
demonstrated  its  cause  and  advanced  views  as  to  its  pathology 
which  are  held  to-day,  and  the  affection  was  properly  identified 
with  his  name. 

Pathology. 

Dupuytren  proved  by  his  dissections  that  the  deformity  is  due 
to  a  contraction  of  the  palmar  fascia  and  that  the  flexor  tendons  of 
the  fingers  are  not  involved  in  it.  His  demonstration  has  been 
confirmed  by  ever}'  subsequent  investigator. 

An  important  point  to  be  remembered  in  considering  the   char- 

^  Chomel  :    "  Essai  sur  le  Rheumatisme." 

^  Boyer  :    "  Traite  des  Mai.  Chin,"  xi.,  46,  1S31. 

3  D'Alibert  :    "  Monographic  des  Dermatoses,"  1S13. 


7i6 


ORTHOPEDIC  SURGERY. 


acter  of  the  deformity  is  that  the  normal  palmar  fascia  is  not  a 
sharply  limited  aponeurosis,  but  shades  off  into  delicate  fibres 
which  are  closely  connected  with  the  skin. 

The  pathological  anatomy  of  the  affection  has  been  established 
by  at  least  a-  dozen  dissections '  which  have  shown  in  all  cases  in 
the  palm  tightly  drawn  bands  of  fibrous  tissue  attached  at  points 
to   the   skin   and  drawing  it  down.     These  bands  can  be  seen  to 


Fig.  706. — Dissection  of  Contraction  of 
Middle  and  Right  Fingers,  from  a  Speci- 
men in  St.  Bartholomew's  Hospital  IVIu- 
seum.  a,  Contracted  band  of  palmar  fas- 
cia, just  below  which  goes  a  band  to  the 
base  of  the  first  phalanx;  ^,  flexor  tendons 
far  beneath  the  palmar  cord  and  near  the 
bone;  <r,  fibrous  sheath  of  flexor  tendons 
binding  them  to  the  bones;  d^  digital  pro- 
longations of  palmar  cord  to  base  of  the 
second  phalanx.     (Adams.) 


Fig.  707. — Dissection  of  Contracted  Little  Finger  in  King's 
College  Museum.  «,  Contracted  band  of  palmar  facia;  b,  flexor 
tendon  lying  much  deeper.     (Druitt.) 


Fig.  708. — Another  View  of  the  Same  Dissection,  Showing 
Still  Better  the  Palmar  Cord  Going  to  the  Second  Phalanx. 
(Druitt.) 


be  enlarged  fasciculi  of  the  palmar  fascia  so  contracted  that  the 
fingers  are  drawn  down  into  the  palm,  while  the  flexor  tendons  lie 
underneath,  normal,  and  in  no  way  involved  in  the  disease. "" 

It  is  not  likely  that  the  skin  takes  any  important  part  in  the  pro- 
duction of  the  contraction,  although  it  has  been  asserted  ^  that  there 

'  Dupuytren  :  "  Lecons  Orales  de  Clin.  Chir.,"  i.,  i,  Brussels,  1852  ;  Goyraud  :  Gaz. 
Med.  de  Paris,  1835  ;  Sevestre  :  Journ.  d'Anat.  et  de  Phys.,  Paris,  1867,  iv.,  249:  Part- 
ridge:   Tr.  Path.  Soc,  London,  1853-54,  v.,  343;   St.  Bathe.  Specimen  (see  Adams). 

==  Richer,  quoted  by  Abbe,  N.  Y.  Med.  Journ.,  April  19th,  1884. 

3  Baum  :    Cent.  f.  Chir.,  1878,  v.,  129. 


DUPUYTREN'S    CONTRACTION  (>/■'    77/ A'   /■/NG/iRS. 


;i7 


was  a  decided  hypcri)lasia  of  it,  and  althou^li  adherent  necessarily, 
it  can  always  be  differentiated  from  the  band  of  contraction. 

Often  small  nodules  are  found  in  the  bands  of  fascia  which  ex- 
amination shows  to  be  small  fibromata. 

The  figures  explain  much  more  clearly  than  any  dcscrifjlion  the 
condition  of  the  hand  in  this  deformity.  Knowing  the  anatomy 
of  the  fascia  it  is  easy  to  see  how,  by  a  contraction  of  the  longi- 
tudinal fibres,  any  degree  of  flexion  of  any  or  all  the  phalanges 
may  be  induced  in  any  of  the  fingers  or  even  the  thumb. 


\ 


Fig.  709.  —  Dupuytren's 
Contraction  Involving  Two 
Fingers. 


1^ 

Wk 

^^8MBIBfe|fc  '" 

^^^fli^^H 

Hi^ 

H^lHi 

■P^  Infl 

^^^^^H^^H 

■iKjr^     .^^H 

HRM 

|P^>A^JH 

^^H 

HlH 

Bff 

^m 

K^^^SiSSi 

v^^^H 

■HbHHShkI 

A-'  ihH^I 

HP 

*'^'^^ 

Fig.  710. — Dupuytren's  Contrac- 
tion Involving  Three  Fingers. 


Fig.  711. — Dupuytren's  Con- 
traction Involving  Chiefly  the 
Little  Finger. 


The  deformity,  is,  in  a  word,  caused  by  a  scar-like  contraction  of 
the  palmar  fascia  or  the  areolar  network  overlying  and  continuous 
with  it,  by  means  of  which  the  digital  prolongations  of  the  fascia 
are  retracted  and  the  fingers  flexed  into  the  palm,  leaving  the 
flexor  tendons  free  and  not  involved.  The  affection  of  the  skin  is 
clearly  secondary  when  it  occurs. 

Etiology  and  Occurrence. 

In  1882,  Dr.  W,  W.  Keen  '  tabulated  all  recorded  cases  and  threw 
a  great  amount  of  light  upon  the  subject  of  the  etiology,  although 
the  whole  question  is  still  far  from  being  settled.  The  male  sex 
is  much  more  commonly  affected,  but,  as  has  often  been  stated, 
wom.en  are  n®t  exempt;    out  of  126  cases,  20  occurred  in  women. 


^  Keen  :    Phila.  Med.  Times,  March  nth,  1SS2,  p.  370. 


7i8 


ORTHOPEDIC  SURGERY. 


•       9t 

ime 

.     13 

•     45 

.     88 

•     17 

er, 

•    65 

In  ji  cases  where  mention  was  made  as  to  which  hand  was  affected, 
it  was  found  that  the  hands  were  affected  in  about  an  equal  propor- 
tion of  the  cases.  The  fingers,  however,  show  a  decided  variation; 
in  105  cases  where  it  is  recorded  which  of  the  fingers  were  attacked, 

The  thumb  was  involved,    . 

The  forefinger  " 

The  middle  finger     " 

The  ring  finger  " 

The  little  finger 

The  ring  and  little  finger  together, 

The  phalanges  also  were  very  unevenly  attacked;  for  in  73  hands 
the  first  phalanx  alone  was  affected  in  15,  the  first  and  second  pha- 
langes in  45,  the  second  phalanx  alone  in  7,  and  in  6  cases  the  third 
phalanx  was  also  involved. 

In  bilateral  cases  it  is  worth  notice  that  the  affection  of  the  two 
hands  is  not  necessarily  the  same  and  rarely  begins  at  the  same 
time.  All  this  has  a  very  important  bearing  upon  the  question  so 
often  discussed  as  to  the  probable  influence  of  trauma  in  the  pro- 
duction of  this  deformity. 

There  are  many'  who  believe  that  the  affection  is  due  to  often- 
repeated  but  slight  traumatism  to  the  palm  of  the  hand,  such  as  one 
would  undergo  for  instance  in  leaning  upon  a  cane,  in  using  an 
engraver's  tool,  an  axe,  or  a  spade,  or  holding  reins  as  in  driving. 
The  affection  is  common,  as  Sir  James  Paget  pointed  out,  in  lock- 
smiths and  wire  workers.  Seventy  patients  examined  by  Mr.  Noble 
Smith  were  found  to  belong  entirely  to  the  working  classes  and  to 
be  elderly  people.  In  Keen's  tables,  however,  the  traumatism  theory 
received  no  support,  for  of  seventy  two  cases  where  the  occupation 
was  recorded,  eighteen  performed  manual  labor,  while  fifty-four 
performed  labor  classed  as  non-manual. 

The  fact  that  the  right  hand  is  not  much  more  frequently  affected 
than  the  left  is  against  the  theory  of  traumatism. 

Other  writers  are  equally  strong  in  their  belief  that  gout  or  a 
similar  constitutional  affection  is  the  cause  of  the  deformity. 
Keen's  tables  analyzed  with  regard  to  this  point  showed  that  in 
forty-eight  cases,  where  a  definite  statement  of  the  presence  or 
absence  of  a  rheumatic,  personal,  or  family  history  was  made,  forty- 
two  were  affected  with  such  a  constitutional  taint,  while  in  six  there 
was  no  such  history.     This  theory  receives  a  further  support  in  the 

'  Goyraud  :  already  quoted  ;  Post  :  Medical  Gazette,  N.  Y.,  1880,  7,  129  ;  Jobert  : 
Gaz.  des  Hop.,  1849,  3,  s.  i..  415  ;  Schultz  :  "  Zur  Aetiol.  der  Verkrlimmung  des  vierten 
Fingers,"  Marburg,  1880  ;  Baum  :  already  quoted  ;  others  are  Dupuytren,  Sanson,  Roque, 
Gerdy,  and  R.  Adams. 


DUPUYTRl'lN'S    CONTNACTJON  ()/'     77//:    /■  7 jXC, /'J^S. 


719 


marked  tendency  to  heredity  tliat  the  affectic^n  shows,  for  there 
was  such  hereditary  liistory  in  one-third  of  Keen's  cases,  and  in 
three  of  them  it  occurred  in  three  generations  and  once  in  four 
generations.'  The  age  of  onset  has  a  still  further  bearing  upon  this 
question,  for  it  is  clearly  an  affection  of  middle  and  later  life. 

Mr.  Adams,  in  twenty  years'  experience  at  the  Orthojjcriic  Hos- 
pital, found  the  affection  to  be  much  more  common  amrjng  fjutlers 
and  in-door  servants  than  among  those  who  did  manual  labor.  He 
says,  "The  cases  which  have  fallen  under  my  observation  have  oc- 
curred in  clergymen,  barristers,  medical  men,  officers  of  the  army 
and  navy,  and  merchants  ;  the  only  condition  common  to  the  whole 
series  being  a  disposition  to  gout." 

Abbe  states  in  his  paper  that  Torty-two  in  forty-eight  cases  seeix 
by  him  did  not  show  a  gouty  diathesis,  and  calls  attention,  very 
properly,  to  the  fact  that  a  rheumatic  personal  or  family  history 
Avould  necessarily  be  found  in  a  large  proportion  of  any  collection 
.of  elderly  people  who  were  asked  about  it,  in  a  country  where 
rheumatism  is  so  common  as  in  America. 

Still  others'-  believe  in  an  inflammatory  cause,  the  result  of  some 
mechanical  injury  to  the  pahn.  The  affection  is  sometimes  due 
to  syphilis,  as  in  cases  reported  by  Ricord  and  Richet,  where  begin- 
ning cases  yielded  to  treatment  by  iodide  of  potash. 

Dr.  Robert  Abbe  points  out  the  insufficiencies  in  the  gouty  and 
traumatic  theories,  and  formulates  a  theory  of  the  nervous  origin  of 
the  affection.  The  working  hypothesis  that  he  assumes  is  "  First, 
a  slight  traumatism,  often  entirely  forgotten.  Second,  a  spinal  im- 
pression produced  by  this  peripheral  irritation.  Third,  a  reflex 
influence  on  the  part  originally  hurt,  producing  insensible  hyper- 
semia,  nutritive  tissue  disturbance,  and  new  growth  shown  in  the 
contracting  bands  of  fascia  and  occasional  joint  lesions  resembling 
subacute  rheumatism.  Fourth,  through  the  tense  contractions  a 
secondary  series  of  reflex  symptoms,  neuralgias,  and  general  sys- 
temic disturbance." 

This  theory  of  Abbe  ^  depends  upon  a  chain  of  events  whose 
necessary  sequence  it  is  not  perhaps  easy  to  see,  but  the  theory 
calls  attention  to  nervous  influence  as  a  factor  in  the  etiology  and 
explains  also  the  frequent  presence  of  neuralgia,  a  point  also  al- 
luded to  by  Lancereaux  and  Smith. 

In  a  case  of  cancer  of  the  breast  operated  upon  b}-  Dr.  Bradford, 
where  the  axilla  was  thoroughly  cleaned  out,  six  months  after  ope- 

'  Bulky:  Med.  Times  and  Gaz.,  1S64,  ii..  21S  ;  Madelung  :  Bed.  klin.  AVoch.,  1S75, 
xii.,29r;    Richer:    already  quoted  ;    Wm.  Adams:   Brit.  ]Med.  Journ.,  June  29th,  187S. 
-  I.angenbeck:    Allg.  Zeitschrift  f.  klin.  Med.,   1841,  i.;  Eichson,  Little, Pitha.  etc. 
3  Abbe  :   N.  Y.  Med.  Record,  ^NFarch  3d,  iSSS. 


720 


ORTHOPEDIC  SURGERY. 


ration  Dupuytren's  contraction  began  in  the  hand  of  the  affected 
side  and  has  followed  the  typical  course. 

Symptoms. 

The  first  noticeable  sign  is  a  small  subcutaneous  nodule  appear- 
ing in  the  palm  of  the  hand  somewhere  about  the  crease  of  the 
palm  which  corresponds  to  the  metacarpo-phalangeal  articulation. 
In  this  stage  it  is  rarely  noted,  and  commonly  the  patient's  atten- 
tion is  first  called  to  the  condition  by  his  inability  to  extend  the 
ring  or  little  finger  as  far  as  he  can  the  others ;  ordinarily  he  speaks 
of  it  as  "  a  stiffness."  Sometimes  he  has  noticed  a  cord  in  the  line 
of  the  ring  finger  which  has  forme'd  from  the  coalescence  of  these 
small  nodules  already  mentioned.  At  this  stage  there  is  rarely  any 
pain  or  discomfort  beyond  the  mechanical  disability,  and  generally 


Fig.  712.— Dupuytren's  Contraction  of  the 
Palmar  Fascia.    (Ripher.) 

the  affection  is  allowed  to  go  on  for  years  until  it  is  noticed  that 
the  cord  in  the  palm  is  growing  more  prominent  and  that  perhaps 
a  second  finger  is  becoming  stiff. 

There  may  be  one  or  several  bands  extending  from  the  wrist  to 
the  proximal  phalanx  of  the  finger,  forming  a  ridge  in  the  palm  of 
the  hand  which  may  be  one-quarter  or  one-half  an  inch  above  the 
level  of  the  rest  of  the  palm.^  The  contraction  may  go  on  until  the 
diseased  fingers  are  drawn  down  into  the  palm  so  forcibly  that 
ulceration  results  from  the  pressure  of  the  finger  tips.  Neuralgic 
pains  are  a  common  symptom;  Abbe  found  that  brachial  neural- 
gias of  one  or  both  arms  and  symptoms  of  irritation  in  the  spinal 
cord  accompanied  the  condition  in  some  of  his  cases  and  were  re- 
lieved by  operation. 

Sugar  is  occasionally  found  in  the  urine  of  these  patients,  as 
pointed  out  by  the  French  writers. "" 

'  Adams,  Brit.  Med.  Jour.,  June  29th,  '78,  p.  231,  f.  6. 

^  Revue  d'Heyem,  t.  xxv.,  "  Ret.  de  I'aponeur.  chez  les  diabetiques." 


DUJ'UYTKEN'S    CUNTRACTION  (jr    77/ A'   /■/Nii/CA'S. 


721 


Dia(;n()Sis. 

Dupuytren's  contraction  is  so  distinctive  in  its  cliriractcristics 
that  it  is  not  likely  to  be  mistaken  for  any  other  affection. 

It  is  an  insidious  but  progressive  contraction  and  flexion  of  one 
or  more  fingers,  more  often  on  the  ulnar  side  of  the  hand.  A  distinct 
and  very  prominent  cord  can  be  felt  in  the  palm,  which  is  not 
directly  over  the  flexor  tendons,  and  which  splits  at  the  base  of 
each  finger  into  tongues  reaching  to  each  side  of  it.  These  bands 
in  the  palm  are  much  tightened  by  any  attempt  to  extend  the 
fingers. 

Flexion  is,  however,  unaffected,  the  joints  are  not  ankylosed  and 
the  affection  is  often  accompanied  with  much  neuralgic  pain.  In  a 
fully  developed  case  the  resistance  of  the  fingers  to  forced  exten- 


''^''' 'IWU  fii^i^ 

Fig.  713. — Vicious  Cicatrix  from  purn.    (Gross.) 


Fig.  714. — Deformity  of  Right  Hand  from  Burn. 
(Erichsen.) 


sion  is  most  marked,  the  skin  is  tough  and  seems  abnormally  thick 
and  adherent. 

Cicatrices  from  palmar  wounds  or  burns  may  be  mentioned  as 
causing  finger  contraction  of  this  same  type,'  but  easily  distinguish- 
able on  careful  examination. 

Affections  which  sometimes  simulate  Dupuytren's  contraction 
are  the  following:  Ankylosis  of  the  fingers  from  rheumatoid  arthri- 
tis, in  a  flexed  position  where  further  ilexion  would  be  impossible 
and  the  nodular  deformity  of  the  joints  would  be  present. 

Sometimes,  after  deep  felons  where  the  tendon  sheath  has  been 
widely  opened,  the  tendon  becomes  prominent  in  the  palm  of  the 
hand,  but  complete  extension  of  the  fingers  obliterates  this  promi- 
nence instead  of  increasing  it,  as  in  contraction  of  the  aponeurosis. 
Sometimes,  from  wounds  of  the  palm,  or  palmar  abscesses,  or  con- 
tusions, the  flexor  tendons  are  affected  and  permanenth'  shortened  ; 
but  there  is  no  band  adherent  to  the  skin  in  the  palm  and  what 
protuberance  there  is  in  the  palm  can  be  effaced  by  bending  the 
elbow,  when  it  will  be  found  that  the  fingers  can  be  extended 
nearly  straight  and  the  slight  prominence  of  the  diseased  tendon 


46 


'  Durel:    Loc.  cit. ,  p.  3; 


722 


ORTHOPEDIC  SURGERY. 


will  have  disappeared,  A  paralysis  or  section  of  the  extensor 
muscles  of  the  fingers  may  cause  a  superficial  resemblance  to  Du- 
puytren's  contraction,  but  the  ease  with  which  they  can  be  straight- 
ened would  at  once  clear  up  the  diagnosis. 

A  contraction  and  flexion  of  the  fingers  is  noted  in  cer- 
tain" diseased  conditions  of  the  nervous  system. 

Prognosis. 

The  prognosis  of  the  affection  without  treatment  is  bad, 
as  far  as  any  improvement  is  concerned.  Life  will  not, 
^  of  course,  be  shortened,  but  a  much  impaired  hand  will  re- 
I  suit,  as  the  inevitable  tendency  of  the  contraction  is  to  be- 
^  come  worse,  although  very  slowly. 
■I  With  a  suitable  operation  an  as- 
%  surance  of  practically  complete  re- 
I    lief  can    be  given  with    but    little 

o  " 

^    tendency  to    a    recurrence  of    the 

0  _ 

g    deformity. 

s  Treatment. 

o 

1  The     methods     of     surgical 
I    treatment  advised  at  the  pres- 

g    ent  time  are :  the  subcutaneous  m- 

■^    cision  of  the  fibrous  bands  as  prac 

^    tised   by  Adams,  or  an  open  inci 

I    sion   with    or  without   the    removal   of  a 

<    part  of  the  contracting  band. 

'S      ■  Mr.    Adams      operates     with    a    small 

6    pointed  tenotome  which   he   enters   at   a 

^    point  a  little  to  one  side  of  the  cord   to 

be  divided,  and  cuts  down  upon  the  fascia 

by  a  gentle  sawing  motion,  being   careful 

not  to  depress  the  point  of  the  knife  too 

much,  until  the  band  is  severed.     For  the      „     fig  716. 

_  A,  Palmar  sphnt;  B,  band- 

first  puncture  he  selects  a  point  near  the  age.  (Adams.) 
wrist  where  the  skin  is  not  too  tightly  bound  down.  A 
second  division  of  the  same  cord  should  then  be  made  between  the 
crease  in  the  palm  and  the  web  of  the  fingers.  The  prolongations 
of  the  fascia  going  to  the  base  of  the  finger  are  then  divided  in  the 
same  way.  If,  after  this,  lateral  or  other  bands  remain  they  should 
be  divided  in  the  same  way.  Pressure  is  made  over  each  puncture 
Avith  a  wet  compress,  the  hand  bandaged,  and  a  splint  applied  hold- 
ing the   fingers   only  partially  flexed;    too   much   extension  before 


DUPIJYTRF.N'S    CON'fh'.lC'/'JON  ()/■     7//A    I- L\( il'lKS. 


723 


the  third  or  fourth  day  Ijcin^^  jjaiiiful.  After  that  a  straightcr 
spHnt  shoukl  be  applied,  and  for  tliree  weeks  it  shoukl  be  worn 
continuously,  bein^r  constantly  adjusted  until  it  is  perfectly  straight, 
and  should  be  worn  at  night  for  some  months.  CompHcated  splints 
with  rack  and  pinion  extension  are  useless  and  absurd. 

The  objection  to  Adams's  operation  is  that  it  sometimes  requires 
10,  20,  or  25  punctures  before  the  contraction  can  be  overcome,  on 
account  of  the  very  intimate  relation  of  the  skin  and  contracting 
band,  and  the  disadvantage  that  it   shares  ^— .^ 

in  common  with  all   subcutaneous  proce- 
dures,  when    contrasted    with    open   inci- 
sions, in  the  lack  of  precision  jDy  the  former 
method.     It  is,  however,  an  admirable  op 
eration  in  every  way. 


I   _ 


/ 


Fig.  717.  Fir   718 

Figs.  717,  718.— Fig.  717  is  the  Left  Hand,  Dec.  21st,  1879.  Fig.  71S,  same  hand  Jan.  14th.  1880, 
three  weeks  after  subcutaneous  operation.  The  crescentic  folds  and  puckerings  of  the  skin  show  well. 
The  apparent  suture  in  the  line  of  the  ring-finger  is  due  to  stretching  of  the  skin.  Two  of  the  punctures 
show  on  the  first  ring  phalan.x,  and  these  joints  are  enlarged.  Good,  but  not  complete  fle.xion  of  this  hand 
was  secured.  The  right  ring-finger  was  completely  cured;  the  little  finger  only  half  extension.  Recontrac- 
tion  took  place  in  the  right  hand  after  three  years,  and  was  relieved  by  a  second  similar  operation. 

Ether  is  not  necessary,  as  cocaine  can  be  used  equally  well  to 
overcome  the  pain.  A  two-per-cent  solution  should  be  injected 
into  the  skin  (not  under  it)  at  the  point  of  puncture  and  no  sensa- 
tion of  pain  will  be  felt.  Two  or  three  drops  will  be  sufficient  at 
each  point  and  the  same  process  should  be  repeated  before  each 
puncture. 


724 


ORTHOPEDIC  SURGERY. 


Trelat  performs  a  similar  operation.  He  enters  a  sharp  teno- 
tome under  the  skin  at  the  most  prominent  part  of  the  band  and 
withdrawing  it  he  substitutes  a  blunt-pointed  one.  With  this  he 
severs  the  attachments  between  the  skin  and  the  band  by  cutting 
in  a  plane  parallel  to  the  surface  of  the  palm  before  proceeding  to 
divide  the  band,  just  as  Adams  does  by  cutting  down  upon  it  trans- 
versely. This  proceeding  he  repeats  at  various  places  until  the 
fingers  can  be  extended,  always  first  cutting  the  fibres  between 
the  shin  and  aponeurosis. 

Dupuytren  was  the  pioneer  in  open  operations,  and  his  simple 
operation  meets  with  much  acceptance  to-day.  It  is  merely  a 
transverse  incision  through  the  skin  and  aponeurosis  where  the 
band  is  most  prominent.  Ordinarily  it  has  to  be  made  in  two  or 
three  places. 

In  practice  Abbe  has  found  that  numerous  transverse  open  in- 
cisions are  as  good  as  subcutaneous  ones.  They  close  by  primary 
union  and  are  healed  in  ten  or  fifteen  days.  With  antisepsis  they 
do  not,  of  course,  add  to  the  risk. 

Goyrand's  operation  consists  of  a  simple  longitudinal  incision  in 
the  skin  along  the  length  of  the  prominent  band  and  after  dissec- 
ting it  free  making  transverse  incisions  enough  to  make  possible  the 
extension  of  the  fingers. 

The  objection  to  Goyrand's  operation  is  the  difficulty  of  isolat- 
ing and  making  the  section  of  the  band  by  his  incision.  Richet's 
modification  of  the  operation  consists  in  making  a  transverse  cut 
at  each  end  of  the  incision  so  that  it  is  possible  to  dissect  up  a  flap 
on  each  side  and  obtain  easier  access  to  the  contracted  band,  which 
can  be  divided  or  excised. 

Busch  advocates  a  V-shaped  incision  whose  base  is  at  the  fold  of 
the  diseased  finger  and  palm  and  whose  apex  reaches  toward  the 
wrist  as  far  as  the  beginning  of  the  contracting  band.  In  more 
extensive  cases  this  may  be  modified  to  an  oval  incision  with  the 
convexity  toward  the  wrist. 

In  choosing  an  operation  one  of  the  open  incisions  is  to  be  pre- 
ferred, because  it  is  simpler  and  plainer;  for  with  proper  antiseptic 
precautions  it  adds  no  risk,  and  it  is  possible  to  see  exactly  the 
condition  of  the  aponeurosis  and  thus  more  accurately  to  remedy  it. 

The  skin  of  the  hand  should  be  rendered  aseptic  and  an  Esmarch 
bandage  applied  and  a  rubber  tube  for  a  tourniquet  tied  tightly 
around  the  wrist.  Then  with  a  subcutaneous  syringe  a  two-per-cent 
solution  of  cocaine  should  be  injected  into  the  skin  along  the  line 
of  the  proposed  incision. 

The  hand  to  be  operated  on  should  be  placed,  with  back  down- 
ward upon  a  table  or  other  hard  surface,  the  wrist  being  steadied 


DUJ'UYTKJ'.N'S   a)NTRACTH)N  O/''    '/'///■:   l/NGENS.         725 

and  the  contracting^  finder  or  finj^crs  placed  slij^litl)-  upon  the 
stretch.  A  tenotome,  if  tenotonny  is  to  be  used,  should  be  inserted 
beneath  the  skin  and  under  the  contracted  fascia,  which  should  be 
divided,  and  the  division  re[)euted  till  the  deformity  is  tliorou^ddy 
corrected. 

Tenotomy,  as  recommended  by  Mr.  Adams,  can  be  repeated  with 
the  details  already  mentioned.  If  the  contracting  band  is  long  and 
prominent,  thou^di  sint^le,  or  if  the  deformity  is  extensive  and  the 
contractions  broad,  oi)en  incisions  are  to  be  preferred  Vo  subcuta- 
neous operations. 

If  the  contractions  seem  widespread  a  V-shaped  or  oval  incision 


S.  iA 


Fig.  yiq. 


Fig.  721. 


Figs.  719,  720,  721. — Appliances  designed  for  the  Mechanical  Reduction  of  Dupuytren's  Contraction. 

should  be  made  to  include  all  the  diseased  area.  Generally  trans- 
verse incisions  of  the  more  prominent  bands  of  the  diseased  fascia 
will  be  enough  to  free  the  fingers;  if  not,  resistant  bands  may  be 
dissected  out  and  removed,  but  it  is  not  advisable  to  remove  any 
large  amount  of  the  palmar  aponeurosis,  because  its  place  m.ust  be 
filled  by  scar  tissue,  which  will  also  contract  and  perhaps  bring 
back  the  deformity.  When  the  bands  have  been  cut  and  the  fin- 
gers straightened,  the  Avound  should  be  sewed  up  as  far  as  practic- 
able, and  an  antiseptic  dressing  applied,  after  which  the  tourniquet 
may  be  removed. 

No  splint  is  needed  and  no  stretching  or  manipulation  of  the  fin- 
gers should  be  attempted  for  a  week  or  ten  days.  Then  the  gentlest 
of  passive  manipulation  is  sufificient  for  all  purposes.      If  the  ope- 


726 


ORTHOPEDIC  SURGERY. 


ration  has  been  thoroughly  performed,  a  relapse  is  not  likely  to 
occur. 

Medical  treatment  is  useless  except  in  cases  where  a  syphilitic 
history  is  present ;  here  iodide  of  potash  should  be  faithfully  tried, 
bearing  in  mind  the  cases  of  Ricord  and  Richet  already  alluded  to. 

Inunctions,  fumigations,  douches,  and  cataplasms  have  all  had 
their  day  and  have  been  completely  abandoned. 

Massage  has  proved  useless  and  extension  of  the  diseased  fingers 
by  manipulation  or  by  means  of  apparatus  has  never  yielded  per- 
manent results.  "  Les  resultats  n'ont  pas  ete  heureux,  la  retraction 
n'a  pas  et^  diminuee  sur  le  moment  et  consecutivement  elle  a  suivi 
une  marche  evidemment  plus  rapide." '  The  very  complicated 
character  of  such  appliances  may  be  appreciated  by  looking  at 
the  figures.^ 

^  Pollailon  :    "  Diet.  Encyc.  des  Sci.  Med.,"  Article  "  Main." 

=  Dupuytren's  Contraction. — Mr.  Phedrau  :  Canada  Lancet,  1886-67,  xix.,  135. 
— Trelat :  Gaz.  des  Hop.,  Paris,  1887,  Ix.,  27. — Homans  :  Boston  Med.  and  Surg. 
Journal,  1887,  cxvi.,  177. — Eulenburg  and  Bernhard:  Deutsche  Med.  Wochenschrift,  1887, 
xiii. — Schmidt :  Bull.  gen.  de  therap.,  Paris,  1887,  cxii.,  145  — Cucco  Barucco  :  Progresso 
Med.,  Napoli,  1887,  i.,  449.— Reib  Mayr:  (app.)  Wien.  Med.  Woch.,  1887,  37,  1092. 
— Adams  and  Reeves:  Brit.  Med.  Journ.,  Feb.  7th  and  14th,  1885;  Aug.  23d,  1884; 
March  7th,  1885. — Regis  :    Semaine  Med.,  No.  39. 


CHAPTER  XXIV. 

FLAT-FOOT   AND    OTHER   AFFECTIONS    OF   THE 

FEET 

Talipes  Valgus. — Congenital  Talipes  Valgus. — Acquired  Valgus.— Varieties  and 
Frequency. — Causation. — Pathological  Anatomy. —  Symptoms. — Diagnosis. 
— Prognosis. — Treatment.— Talipes  Equinus. — Non-Deforming  Club-Foot. 
— Talipes  Calcaneus. — Pes  Cavus. — Deformities  of  the  Toes. — Hallux 
Valgus. — Hallux  Varus. — Hallux  Rigidus. — Hammer  Toe. — Deviations  of 
the  Small  Toes. — Morton's  Painful  Affection  of  the  Foot. — Teno-Synovitis. 
— Other  Minor  Affections. 

Talipes  Valgus — Flat-Foot. 

Talipes  Valgus  is  a  deformity  characterized  by  a  marked  prona- 
tion of  the  foot  with  obliteration  of  its  arch.  There  is  also  abduc- 
tion of  the  front  part  of  the  foot. 

The  deformity  is  also  called  splay  foot ;  in  German  Plattfuss  and 
in  French,  Pied  bot  valgus. 

The  affection  is  either  congenital  or  acquired. 

Congenital  Flat-Foot  is  not  so  rare  an  affection  as  many  text- 
books would  have  us  believe.  Kiistner '  examined  with  regard  to 
this,  150  new-born  children  taken  consecutively,  and  13  (8.6  per 
cent)  of  these  presented  marked  congenital  fliat-foot ;  that  is,  the 
sole  of  the  foot  was  convex  and  the  whole  foot  pronated  or  rolled 
out.  Sometimes  there  is  present  congenital  calcaneo-  or  equino. 
valgus. 

Adams  found  42  cases  of  congenital  valgus  in  764  cases  of  con- 
genital deformity  of  the  feet;  in  15  others  there  was  v^arus  of  one 
foot  and  valgus  of  the  other.  Of  the  42  cases,  15  were  of  the  right 
foot,  10  of  the  left,  and  17  of  both. 

The  characteristics  of  the  deformity  of  congenital  valgus  are  a 
strongly  pronated  and  abducted  position  of  the  foot  relatively  to 
the  axis  of  the  leg.  Frequentl}'  two  projections  can  be  seen  on 
the  inner  side  of  the  foot  corresponding  to  the  head  of  the  astrag- 
alus and  the  side  of  the  scaphoid  bone. 

'  Archiv  f.  klin.  Chir.,  iSSo,  25,  p.  397. 


728  ORTHOPEDIC  SURGERY. 

Acquired  Valgus. 

The  acquired  variety  of  this  deformity  is  much  more  common 
than  the  congenital.  Adams  found  i8i  cases  of  valgus  deformity 
and  Bo  of  equino-valgus  in  999  cases  of  acquired  deformities  of  the 
feet. 

Acquired  valgus  deformity  of  the  foot  is  of  different  varieties; 
viz.,  rhachitic,  static,  paralytic,  spastic,  and  traumatic  or  inflam- 
matory. 

Rliachitic  Valgus. — This  variety  is  chiefly  seen  in  connection  with 
other  evidences  of  rickets.  It  may  be  found  associated  with  knock- 
knee,  and  the  coincidence  is  so  common  that  it  has  been  regarded 
as  one  of  the  causes  of  knock-knee,  but  it  may  also  be  seen  in  the 
very  early  stages  of  rickets  before  osseous  deformity  is  marked. 
Rhachitic  valgus  is  seen  usually  before  the  seventh  year. 

Static  Valgjis  {Typical Fiat-Foot). — This  form  is  the  most  common 
of  the  different  varieties  of  valgus.  It  is  also  termed  pes  valgus 
adolescentium,  pes  staticus  adultorum,  pes  planus,  etc. 

Static  valgus  is  sometimes  termed  "  spurious  "  valgus,  but  there 
seems  to  be  no  reason  why  this  most  common  and  important  form 
of  valgus  should  be  so  distinguished.  It  is  most  commonly  seen  in 
young  adolescents  at  the  time  approaching  puberty.  It  may,  how- 
ever, be  seen  in  younger  children  and  is  in  some  cases  associated 
with  so  mild  a  degree  of  rickets  that  it  is  almost  impossible  to 
know  whether  it  should  be  classed  as  rhachitic  or  static. 

The  distortion  appears  in  weak  patients  of  imperfect  muscular 
development,  whether  they  are  children,  adolescents,  or  even  adults. 
Its  occurrence  is  favored  by  ill  health  of  all  sorts,  and  by  anything 
which  tends  to  depress  the  general  condition.  Rapid  growth  is  an 
important  factor  in  producing  it,  inasmuch  as  the  recently  formed 
tissues  are  not  yet  able  to  do  their  increased  work.  It  often  coex- 
ists with  lateral  curvature  of  the  spine.  Mr.  Roth  finds  flat-foot 
present  in  two  out  of  every  three  cases  of  lateral  curvature. 

Mr.  Haward,  in  the  Orthopedic  Department  of  St.  George's 
Hospital,  found  65  per  cent  of  all  cases  of  flat-foot  to  occur  be- 
tween the  ages  of  fifteen  and  twenty. 

The  deformity  occurs  especially  in  adults  who  are  obliged  to 
stand  continuously,  such  as  waiters,  nurses,  barbers,  bakers,  etc.  It 
occurs  sometimes  in  elderly  persons. 

Much  discussion  has  taken  place  as  to  the  causation  of  common 
flat-foot,  but  there  can  now  be  no  question  that  the  deformity  re- 
sults from  the  superincumbent  weight  falling  upon  an  ankle  and 
foot  unable  to  sustain  it.  It  is  the  result  of  a  disproportion  be- 
tween the  body  weight  and  the  apparatus  for  sustaining  it. 


FLAT-FOOr  AND  077/ Fh'  AI'l'liCTIONS  OJ'    TJlli  /■r.h/r.     729 

Hueter  is  of  the  belief  that  the  (leformity  is  an  anomaly  of 
growth,  i.e.,  a  persistence  of  the  physioloj^ical  pronation  in  the 
.medio-tarsal  articulation  which  is  normal  when  the  child  is  at  an 
age  for  sustaining  weight,  and  that  in  static  flat-foot  an  excess  in 
the  growth  of  portions  of  the  tarsal  bones  takes  place  and  a  de- 
formity results. 

In  opposition  to  this  view,  Volkmann  has  called  attention  to  the 
fact  that  the  foot  may  become  pronated  before  walking  is  at- 
tempted, and  even  that  flat-foot  may  develop  at  the  early  age  of 
eight  or  ten  months.  Moreover  that  in  children  who  do  not  walk 
until  fifteen  months  the  foot  changes  to  the  normal  pronated  posi- 
tion, just  as  may  be  seen  in  children  who  have  walked.  On  these 
grounds,  Volkmann'  holds  that  the   changes  in  the  bones  w^hich 


^m. 


rn^i 


Fig.  722. — Sole  of  Infant  Ten  Months  Old. 


bring  about  the  pronation  of  the  foot  are  spontaneous  and  do  not 
result  from  the  superposition  of  body  weight. 

•  The  sole  of  an  infant  is  flatter  than  that  of  an  older  child.  It  is 
slightly  turned  in  and  the  absence  of  an  arch  may  be  seen  by  the 
tracing  taken  on  smoked  glass  from  the  foot  of  a  child  ten  months 
old.     The  arch  begins  to  form  at  about  the  age  of  one  year. 

Other  writers  have  regarded  the  deformity  as  chiefly  due  to  a 
contraction  of  the  extensor  and  pronator  groups  of  muscles. 

The  most  thorough  investigation  of  the  subject  has  been  made 
by  Lorenz^  who  concludes  that  the  deformity  is  due  to  an  altera- 
tion in  the  positions  of  the  astragalus,  os  calcis,  and  scaphoid  which 
is  simply  an  excessive  pronation  of  the  front  of  the  foot  at  the 
medio-tarsal  joint.  This  distortion  in  the  position  is  the  effect  of 
weight  falling  upon  a  foot  which  is  not  able  to  sustain  it. 

Lorenz  has  also  pointed  out  that  in  addition  to  these  changes  in 
severe  cases  evidences  of  irritation   of    the   periosteum    could    be 


''Cent.  f.  Chin,  Feb.  12th,  1881. 


■Platfuss,"  Stuttgart,  1SS3. 


730 


ORTHOPEDIC  SURGERY. 


found  on  the  outer  side  of  the  head  of  the  astragalus  and  the 
upper  part  of  the  sustentaculum  tali,  and  in  many  instances  evi- 
dences of  the  formation  of  bone  from  irritation,  such  as  osteo- 
phytes, -etc. 

Traumatic  or  Inflammatory  Fiat-Foot. — The  class  of  flat-foot  due 
to  miscellaneous  causes  is  not  very  extensive  or  very  commonly 
encountered.  The  most  common  of  traumatic  causes  is  Pott's 
fracture,  where  a  valgus  is  the  result  of  inefficient  treatment  or  of 
a  very  severe  and  intractable  fracture.  As  a  result  of  ankle-joint 
disease  accompanied  by  considerable  destruction  of  tissue  one 
sometimes  sees  very  marked  flat-foot  which  does  not  tend  to  grow 
worse  because  there  is  generally  firm  ankylosis  in  the  ankle ;  but 
the  deformity  may  be  severe.  Injury  of  the  long  peroneus  may  give 
rise  to  this  deformity  without  any  other  cause,  and  Duchenne  has 
considered  it  due  to  a  functional  impotence  of  the  long  peroneus. 


Fig.  723. — Outer  View  of  the  Bones  in  Flat-  Ftg.  724. — Inner  Sectional  View  of  the  Skeleton 

Foot  Showing  New  Joint  Between  the   Fibula  in  Fiat-Foot.     (After  Lorenz.) 

and  Os  Calcis. 

Pathological  Anatomy  of  Flat-Foot . — The  anatomical  changes  are 
much  the  same  in  congenital  and  acquired  talipes  valgus. 

The  bones  in  congenital  flat-foot  even  in  severe  cases  show  but 
little  alteration  in  shape.  The  astragalus  is  turned  obliquely  to 
one  side  and  downward,  and  the  angle  of  the  articulation  faces 
more  to  the  side  than  is  normal.  The  end  of  the  os  calcis  may  be 
slightly  raised.  The  scaphoid  is  turned  to  the  outer  side  and  is 
rotated  somewhat  on  its  central  axis,  so  that  the  outer  side  is 
slightly  raised  and  the  inner  side  is  lowered — the  arch  of  the  foot 
is  obliterated  and  the  inner  border  is  more  often  convex  rather 
than  concave. 

Holl  has  described  a  congenital  fusion  of  the  os  calcis  with  the 
scaphoid  and  a  distortion  of  the  dislocated  astragalus  constituting 
a  form  of  congenital  flat-foot.' 

In  acquired  flat-foot  the  anatomical  changes  show  very  few  alter- 
ations in  the  shape  of  the  bone  in  light  cases.  The  astragalus  is 
turned   obliquely  forward  and  downward   and  its  head  altered  in 

'Arch.  f.  klin.  Chir.,  xxv.,  925. 


FLAT-FOOT  ANJ)  OTJlliR  y\  I'l'FCTJONS  ()/■     I  III:   riU-.r. 


7'6i 


position,  so  that  its  facet  is  on  tlic  outer  side;  the  scaplioid  is 
rotated,  and  its  outer  side  raised. 

SHght  alterations  in  the  shape  of  the  bones  are  ntjted  and  in 
severe  cases  the  external  malleolus  is  somewhat  flattened  and 
rounded. 

In  severe  cases  there  is  practically  almost  complete  dislocation 
of  the  scaphoid  outward,  and  sometimes  there  is  a  formation  of 
osseous  deposit  which  prevents  the  normal  amount  of  play  between 
the  scaphoid  and  astragalus.  Alterations  in  the  shape  of  the  sus 
tentaculum  tali  and  of  the  astragalus  as  it  articulates  with  this  are 
also  noticed. 

Of  the  ligaments  the  most  important  are  the  inferior  calcaneo- 
scaphoid,  and   the  calcaneo-astragaloid    ligaments.     The    latter   of 


Fig.  725. — Astragalus  in  Fiat-Foot  Seen  from  the 
Outer  Side. 


Fig.  726. — Astragalus  in  Fiat-Foot  with  Bony 
Prominence  at  jr. 


these  does  more  to  keep  the  "  keystone  "  of  the  arch  in  place  than 
does  any  arrangement  of  its  components.  In  the  maintenance  of 
the  normal  concavity  all  the  ligaments  of  the  sole  of  the  foot 
contribute,  but  to  a  less  extent. 

In  severe  flat-foot,  owing  to  the  change  in  the  form  of  the  bones, 
there  is  a  limitation  in  the  amount  of  motion  at  the  ankle-joint. 
The  normal  amount  of  motion  is  stated  by  Schreiber  to  be  from 
76°  to  80°.     In  flat-foot  it  may  be  restricted  to  45°  or  even  32°. 

Prcdisjyosiiig  Ca?fsrs. — If  the  bared  normal  foot  be  placed  upon 
the  floor,  it  Avill  be  found  that  the  outline  of  the  inner  side  becomes 
altered  when  weight  is  thrown  upon  the  foot,  the  internal  malleo- 
lus becomes  more  prominent  and  is  apparently  nearer  the  floor. 
A  slight  amount  of  this  pronation  of  the  foot  is  normal,  the  excess 
is  checked  by  the  strength  of  the  ligaments  and  of  the  muscles. 


732 


OR  THOPEDIC  S  URGER  V. 


The  muscles  which  by  their  tonicity  tend  to  assist  the  Hgaments 
in  maintaining  the  foot  in  its  normal  position  are  especially  those 

which  pass  around  the  inner  malleolus 
to  be  inserted  in  the  anterior  part  of 
the  sole,  and  of  these  the  chief  is  the 
tibialis  posticus.  The  tibialis  anticus 
and  peroneus  longus  assist  these  mus- 
cles in  a  measure.  Sayre  attributes 
very  great  importance  to  the  action 
of  the  tibialis  anticus  and  regards  pa- 
ralysis of  that  muscle  as  a  prominent 
factor  in  the  production  of  flat-foot ; 
but  Golding-Bird  '  examined  fifty  cases 
of  fiat-foot  witho-ut  finding  paralysis 
of  the  tibialis  anticus,  and  Whitman  ^ 
found  no  such  paralysis  in  his  forty- 


FiG.  727. — Dislocation  of  Astragalus  in 
Congenital  Talipes  Valgus. 


five  cases.  The  tibialis-posticus  ten- 
don presses  directly  upon  the  inner 
aspect  of  the  head  of  the  astragalus 
and  tends  to  force  it  outward  and 
backward. 

In  long-continued  standing  muscu- 
lar fatigue  is  inevitable.  The  foot 
loses  the  support  of  the  muscles  and 
the  weight  comes  directly  upon  the 
ligaments;  when  this  is  repeated  often 
or  is  continued  for  long  periods, 
stretching  of  the  ligaments  is  inevita- 
ble. The  weaker  the  muscular  devel- 
opment the  sooner  the  muscles  will 
become  fatigued,  and  the  less  resist- 
ance the  ligamentous  bands  will  pos- 
sess. Any  yielding  of  these  ligaments 
will  be  manifested  by  a  diminution  in 
the  concavity  of  the  inner  side  of  the 
sole,  for  the  outer  side  of  it  already 
touches  the  ground,  and  is,  therefore, 
well  supported,  and  the  more  yielding 
of  the  ligaments,  the  greater  the  pro- 
nation of  the  foot. 

An  important  factor  in  the  produc- 
tion of    flat-foot  is  the   "  attitude    of  ^^';^.-' 
rest "    commented    on    at    length    by 


Fig.  728. —Attitude  of  Rest. 


'Guy's  Hosp.  Rep.,  1883,  vol.  xli.       ^  Bost.  Med.  and  Surg.  Journal,  June  14th,  i5 


FLAT-FOOT  ANJ)  OTII I'J^  A I'l' liCTIONS  ()/■■    TJII-:  /■/■:/■  V.     733 

Arbuthnot  Lane'  The  active  position  of  tlic  foot,  the  jKjsition 
assumed  when  active  work  is  to  be  done,  is  adduction  ;  abduction 
is  the  position  which  necessitates  the  least  muscular  activity,  and 
consequently  the  greatest  ligamentous  support.  The  latter  is  the 
position  assumed  by  individuals  of  poor  muscular  development,  and 
favors  the  stretching  of  ligaments  and  the  destruction  of  the  arch 
of  the  foot. 

Ill-fitting  boots  of  all  sorts  put  the  proper  weight-bearing  mech- 
anism of  the  foot  at  a  disadvantage  and  impede  its  functions,  con- 
sequently the  strain  comes  more  heavily  upon  the  ligaments  of  the 
arch,  and  flat-foot  is  favored. 

Pointed  shoes  also  favor  a  gait  with  the  feet  turned  out,  which 
as  Whitman  '  has  shown,  favors  the  development  of  flat-foot. 

Weak  Ankles. 

Analogous  to  the  form  of  flat-foot  due  to  weakness  of  the  mus- 
cles, is  the  affection  commonly  known  as  weak  ankles,  which  is  fre- 
quently seen  in  growing  children  and  which  is  due  to  the  lack  of 
strength  of  the  tibialis  posticus,  tibialis  anticus,  and  the  plantar 
muscles.     The  feet  are  pronated  and  there  is  a  prominence  of  the 


Fig.  729. — Paralytic  Talipes 
Valgus. 


Fig.  730. — Talipes  Valgus  Adolescentium.     a,  Scaphoid;  b.  head 
of  ."Astragalus;  c,  internal  malleolus. 


internal  malleoli.  This  affection,  if  not  corrected,  may  in  certain 
cases  lead  to  a  permanent  distortion  of  the  astragalus  and  a  verita- 
ble flat-foot. 

The  foot  assumes  in  most  cases  the  position  of  valgus  after  osti- 
tis of  the  tarsus.  The  front  of  the  foot  is  twisted  to  the  outer  side 
and  the  arch  depressed. 

Boots  tightly  laced  about  the  ankle,  compressing  the  ankle  and 
interfering  with  the  free  play  of  the  muscles  holding  the  foot  in 
proper  place,  will,  if  worn  too  consta-ntly  by  young  children,  occa- 
sion weak  ankles  and  flat-foot. 

'Guy's  Reports,  vol.  xxix. ,  p.  256. 

-Whitman:  Transactions  of  the  Am.  Orthop.  Society,  vol.  i. 


734 


ORTHOPEDIC  SURGERY. 


Symptoms. — The  physical  signs  by  which  flat-foot  is  recognized 
will  be  better  appreciated  by  a  glance, at  the  figure  than  by  any 
amount  of  verbal  description.  Instead  of  the  normal  arching  up- 
ward of  the  inner  border  of  the  foot  this  border  either  lies  flat  on 
the  ground,  or  in  a  varying  degree,  it  is  less  arched  than  is  usual. 
The  foot  has  the  appearance  of  being  not  only  broad,  but  also  ab- 
normally long;  it  is  more  or  less  everted,  and  in  severe  cases  the 
head  of  the  astragalus  and  the  scaphoid  tubercle  form  a  marked 
bony  prominence  at  the  middle  of  the  inner  border  of  the  foot. 

Occasionally  on  inspection  it  seems  as  if  a  foot  were  normally 
arched,  but  when  a  tracing  of  the  foot-print  is  made  it  will  be  seen 
that  the  inner  border  of  the  foot  is  less  a  curved  line  than  it 


Fig.  731. — Normal  Foot. 


Fig.  732.— Fiat-Foot.  Fig.  733.— Fiat-Foot. 

Prints  of  Soles  of  Normal  and  of  Fiat-Foot. 


Fig.  734.— Fiat-Foot. 


should  be.  This  tracing  is  most  simply  made  as  follows:  the 
patient  wets  the  sole  of  the  foot  in  a  basin  of  water  and  then,  after 
shaking  off  the  extra  water  which  drips  from  the  foot,  stands  for 
an  instant  upon  a  piece  of  ordinary  brown  wrapping  paper  spread 
smoothly  on  a  hard  floor.  The  foot  is  then  lifted,  and  the  outline 
of  the  wet  surface  is  quickly  drawn  in  lead  pencil.  The  least 
variation  from  the  normal  can  thus  be  immediately  detected. 

The  inner  malleolus  is  more  prominent  than  it  should  be,  and,  of 
course,  nearer  to  the  ground,  the  whole  foot,  in  fact,  is  in  an  altered 
relation  to  the  axis  of  the  leg.  It  seems  to  have  been  distinctly 
displaced  outward. 

In  severe  cases  the  inner  border  of  the  foot  presents  a  convex 
outline  and  the  outer  border  is  raised  so  that  the  weight  is  trans- 
mitted more  improperly  than  ever.  This  elevation  of  the  outer 
border  of  the  foot  is  the  result  of  a  contraction  of  the  peronei 
muscles  and  ultimately  of  the  gastrocnemius,  the  result  of  long- 
continued  reflex  irritation. 


FLAT' FOOT  AND  OTHER  AFFECTIONS  OF   77//-:  /■/•./■7\ 


735 


Manipulation  of  the  foot  is  sometimes  not  attended  with  j)ain, 
at  other  times  any  attempt  at  replacement  is  very  uncomfortable 
to  the  patient.  As  a  rule,  in  slight  cases  it  is  possible  to  return 
the  foot  gently  with  the  hands  to  a  correct  position,  when  the 
weight  is  not  borne  upon  it.  In  severe  or  long- 
standing cases  it  is  not  generally  practicable  to 
rectify  the  foot  without  the  administration  of 
ether  and  the  use  of  considerable  force. 

Tenderness    and    Pain. — Tender     points     are 
almost  constantly  present   in   marked  fiat-foot. 


Fig.  635.— Flat- Foot  Occurring  in  a  Young  Rhachitic 
Child. 


Fig.  736. — Talipes  Valgus  from  Injury. 


Fig.  737. — Static  Valgus  with  Pronation  of  the  Foot. 


Their  location  is  characteristic  and  pain  and  sensitiveness  to  pres- 
sure are  marked.  These  points  are,  over  the  astragalo-scaphoid 
articulation  at  the  inner  border  of  the  foot,  in  front  of  the  internal 
malleolus,  and  at  the  base  of  the  first  and  fifth  metatarsal  bones.  A 
less  common  point  is  to  be  found  in  front  of  the  external  malleolus. 


736 


ORTHOPEDIC  SURGERY. 


These  tender  points  may  become  exquisitely  sensitive  to  pressure 
and  to  weight  bearing.  In  acute  cases  there  may  be  swelling, 
localized  heat  and  redness  of  the  skin,  as  for  instance  at  the  base 
of  the  first  metatarsal;  and  it  must  be  noted  that  the  degree  of 
flat-foot  does  not  influence  the  amount  of  pain  and  tenderness 
present.  The  pain  is  often  most  severe  in  the  least  marked  cases, 
and  in  other  cases  where  the  structural  change  is  very  advanced 
it  may  be  insignificant. 

The  feet  in  this  condition  are  apt  to  sweat  profusely,  and  often 
one  notices  a  congestion,  and  in  long-continued  cases  the  thicken- 
ing and  vascularity  of  the  superficial  tissues  may  be  very  marked. 
Swelling  of  the  feet  and  legs  is  often  an  accompaniment  of  severe 
cases  and  may  become  very  troublesome.     The  gait  is  characteris- 


FiG.  738. — Paralytic  Valgus. 


Fig.  739. — Rhachitic  Valgus. 


tic  in  a  measure,  as  the  feet  are  generally  more  everted  than  nor- 
mal, and  in  painful  cases  it  will  be  noted  that  in  standing  the  patient 
deliberately  throws  the  foot  over,  so  that  the  weight  is  borne  more 
upon  the  inner  border  than  is  normal.  There  is  a  lack  of  elasticity 
to  the  gait,  and  this  is  a  symptom  often  complained  of  by  the  more 
intelligent  patients  who  find  their  feet  stiff  and  clumsy. 

Pain. — The  subjective  symptoms  are  constant  and  characteristic. 
The  complaint  is,  that  after  standing  upon  the  feet  for  any  time, 
pain  comes  on  and  becomes  so  severe  that  it  shoots  up  the  legs, 
sometimes  even  as  far  as  the  thighs.  It  is  somewhat  lessened  by 
sitting  down,  but  when  once  it  is  present,  it  is  likely  to  last  for 
many  hours.  It  continues  into  the  night  and  may  be  so  severe  as 
to  prevent  sleep.  The  pain  does  not  necessarily  correspond  to  the 
amount  of  deformity  present. 

Children,  as  a  rule,  do  not  seem  to  suffer  pain,  however  severe 


FLAT-FOOT  AND  OTJfFU  AFFKCVVONS  ()/■■   Till-:  l-l:!'//'.     737 

the  flat-foot  maybe;  but  occasionally  a  cliild  of  feeble  develop- 
ment will  cry  toward  evening  from  the  pain  in  his  feet,  and  may 
on  that  account  sleep  uneasily  for  the  first  part  of  the  night.  Ex- 
amination will  probably  show  an  abnormal  degree  of  flat-foot,  and 
the  pain  will  be  at  once  relieved  by  suitable  treatment. 

Children  suffering  from  this  distortion  are  more  liable  to  suffer 
from  sprains  of  the  ankle,  and  they  may  be  less  active  in  their 
play. 

The  symptoms  may  begin  suddenly  or  gradually.  Sometimes, 
where  it  is  evident  that  flat-foot  must  have  been  present  for  a  long 
time,  pain  and  tenderness  will  suddenly  come  on,  perhaps  sponta- 
neously or  perhaps  immediately  after  some  slight  wrench  or  twist 
of  the  foot  in  walking. 

Whitman  '  has  called  attention  to  a  feeling  of  stiffness  in  the  foot 
after  sitting  for  any  length  of  time  or  upon  rising  in  the  morning, 
a  symptom  which  is  by  no  means  uncommon. 

Diagnosis. — The  diagnostic  sign  upon  which  one  relies,  is  a  greater 
or  less  breaking  down  of  the  arch  of  the  sole  of  the  foot,  with  a 
pronation  of  the  foot  which  is  less  evident  at  first  sight  than  the 
defective  arch.  The  pronation  is  chiefly  noticeable  as  a  promi- 
nence of  the  internal  malleolus. 

In  acquired  flat-foot  in  adults  and  adolescents  a  characteristic 
symptom  is  pain  in  the  foot  and  legs,  which  comes  on  after  standing 
and  is  worse  at  night  than  in  the  morning.  The  association  of 
tender  points  in  the  characteristic  places  would  establish  the  diag- 
nosis, even  if  associated  with  only  a  very  little  breaking  down  of 
the  arch  of  the  foot. 

It  would  seem  as  if  the  diagnosis  were  so  simple  that  a  mistake 
was  impossible,  but  there  is  scarcely  any  affection  more  frequently 
overlooked  and  mistaken  for  other  afTections  than  flat-foot.  There 
is  no  need  of  entering  upon  any  elaborate  differential  diagnosis, 
for  mistakes  are  oftenest  the  result  of  carelessness. 

It  is  a  wise  precaution  to  investigate  the  condition  of  the  arch  in 
all  painful  feet. 

Rheumatism  of  the  foot  is  most  often  assumed  as  the  cause  of 
the  pain  in  cases  where  the  real  condition  is  overlooked.  It  is  not, 
however,  accompanied  by  the  peculiar  structural  changes  described 
as  characteristic  of  flat-foot. 

Strains  and  wrenches  of  the  foot  may  all  lead  to  a  condition  of 
sensitiveness  and  pain  which  is  naturally  aggravated  by  standing 
and  walking,  but  the  arch  of  the  foot  is  normal  and  the  character- 
istic tender  points  are  not  present. 

Prognosis. — In  painful  acquired  flat-foot  man}*  cases  after  months 

'  Whitman:  Bost.  M.  and  S.  Journ.,  June  14th,  iSSS,  p.  ^98. 

47  ' 


738 


OR  THOPEDIC  S  URGER  V. 


and  years  of  pain  the  foot  becomes  accustomed  to  its  altered  posi- 
tion and  painful  symptoms  cease,  but  of  course,  the  arch  is  perma- 
nently broken  down  and  the  pronated  position  is  permanent.  In 
other  cases,  however,  the  painful  symptoms  continue  and  become 
worse  rather  than  better,  as  years  go  by.  The  condition  may  per- 
sist almost  indefinitely,  a  constant  source  of  pain  and  disability. 

The  results  of  treatment  are  immediate  and  satisfactory.  In 
cases  of  average  severity,  relief  can  almost  always  be  given  by  very 
simple  measures.     A  spontaneous  cure  is  not  to  be  expected. 

Even  after  deformity  of  the  bone  takes  place  and  the  distortion 
is  confirmed,  a  perfect  functional  foot  may  be  obtained  if  the  mus- 
cular   development    of   the    leg  is  good.     A  prominent    "sprint" 


Fig.  740.— Boot  for  the  Left  Foot  Worn 
by  Patient  with  Severe  Fiat-Foot,  Showing 
Characteristic  "  Treading  Over"  of  the  Shoe. 


Fig.  741. — Soles  of  Severe  Fiat-Foot. 


runner  with  a  fine  record  of  success  showed  on  examination  by  Dr. 
D.  A.  Sargent,  of  the  Hemenway  Gymnasium,  well-marked  flat- 
foot. 

The  prognosis  of  a  valgus  deformity  from  inflammatory  or  par- 
alytic causes  varies  necessarily  according  to  the  nature  and  degree 
of  the  original  affection. 

Little  need  be  said  of  the  spastic,  paralytic,  traumatic  or  inflam- 
matory forms  of  valgus.  The  distortion  resembles  that  of  other 
forms,  and  the  requisite  treatment  is  to  be  conducted  on  the  same 
principles  as  are  needed  for  the  ordinary  varieties  of  flat-foot. 

T/ie  Treatment  of  Fiat-Foot. — The  treatment  of  flat-foot  will  de- 
pend upon  the  nature  of  the  deformity,  its  severity,  and  duration. 
In  children,  the  general  condition  of  the  patient  must  be  cared  for, 


]'LAT-FOOT  AND  OTJIliN  A /■/'KC'/'/ONS  <)/■    THI:   hl:l:T. 


739 


and  i^'iins  t.ikcn  to  increase  tlie  tf)ne  of  the  system.  In  rhacliitic 
subjects  this  part  of  the  treatment  must  receive  tiiorough  attention. 

In  the  milder  cases  in  older  children,  it  is  better,  if  possible,  to 
correct  the  deformity,  by  increasini^  the  h)cal  muscular  tonicity 
rather  than  by  the  use  of  apparatus.  This  can  sometimes  be  ac- 
complished by  exercising  the  muscles  most  at  fault.  The  exercise 
best  suited  to  accomplish  this  is  as  follows:  The  patient  stands  on 
both  feet  with  the  heels  together  and  the  toes  pointed  out;  he  then 
rises  on  the  toes  as  high  as  possible,  slowly  and  gradually,  and 
while  standing  in  that  position  the  heels  should  be  separated  as 
widely  as  possible,  and  slowly  lowered  to  the  ground.  This  exer- 
cise will,  sometimes,  be  slightly  painful  at  first,  in  cases  of  irritated 
flat-foot,  but  it  can  be  gradually  increased  and  should  finally  be 
done  twenty  or  thirty  times  each  night  and  morning.  Walking  on 
tip-toe  regularly  and  systematically  for  some  time  each  day  is 
equally  beneficial. 

Whether  attempted  alone  or  in  conjunction  with  the  support  of 
the  arch  of  the  foot,  these  method  of  exercise  are  most  useful  ad- 
juvants in  the  treatment  of  flat-foot  in  children  or  adults. 

Only  the  mildest  cases,  however,  can  be  treated  by  gymnastics 
alone.  In  most  cases  the  standing  position  is  characterized  by  so 
bad  a  position  of  the  feet  that  increase  of  the  deformity  is  inevita- 
ble, unless  by  some  means  the  arch  of  the  foot  is  sustained  in  an 
approximately  correct  position.  This  is  most  easily  accomplished 
by  a  thin  iron  inside  sole,  shaped  to  fit  the  arch  of  a  normal  sole 
and  worn  inside  the  boot. 

Felt  or  horse-hair  or  leather  pads  placed  under  the  hollow  of 
the  foot  are  manifestly  untrustworthy,  but  even  those  will  often 
afford  temporary  relief. 

A  plate  is  made  of  thin  hammered  steel,  and  should  extend  from 
the  ball  of  the  foot,  backward  to  the  heel,  follow^ing  the  outline  of 
the  outer  border  of  the  foot  and  heel,  and  at  the  inner  surface 
rising  as  far  as  is  required  to  give  support  to  the  arch  of  the  foot, 
it  will  rarely  have  to  come  higher  than  the  tubercle  of  the  scaphoid. 
Its  limits  are  shown  in  the  figure,  and  the  sketch  of  the  plate  unap- 
plied may  give  an  idea  of  its  construction. 

A  most  efficient  form  of  sole  plate  has  been  devised  by  Dr.  Whit- 
man,' who  has  demonstrated  the  practical  use  of  the  appliance 
in  a  number  of  successful  cases,  and  the  plate  has  proved  in  the 
writers'  hands  a  very  satisfactory  one. 

It  is  necessary  to  take  a  plaster  cast  of  the  foot  in  order  that  this 
plate  may  be  properly  applied.  This  is  done  with  the  leg  lying  on 
its  outer  side  and  held  as  nearly  as  possible  in  a  corrected  position. 
'Whitman:  Trans.  Am.  Orthopedic  Association,  vol.  1. 


740 


ORTHOPEDIC  SURGERY. 


There  points  are  then  marked  as  the  boundaries  of  the  plate.     A  is 
beneath  the  ball  of  the  great  toe,  B  beneath  the  inner  tuberosity  of 


Fig.  742.— Valgus  Sole  Plate  for  Right  Foot. 


Fig.  743. — Valgus  Sole  Plate  Applied. 


the  OS  calcis,  and  C  just  in  front  of  and  below  the  internal  malleo- 
lus opposite  the  head  of  the  astragalus.  A  plate  is  constructed  on 
lines  connecting  these  points  in  the  way  that  can  be  seen  in  the 
figures. 


Fig.  745. 
Figs.  744,  745. — Whitman's  Valgus  Plates. 

Mr.  Thomas,  of  Liverpool,  builds  up  the  heel  and  sole  of  the  shoe 
on  the  inner  side  as  can  be  seen  in  the  figure.     In  this  way  it  is  im- 


FLAT-FOOT  AND  OTIII'.R  A !■  I'l'.CTIONS  Ol'    77//':  /•/■./■/T. 


74' 


possible  for  the  patient  to  stand  witli  pronated  feet,  for  they  are 
necessarily  scrmevvhat  raised  at  the  inner  border.  Steel  sole  plates 
offer  a  slight  advantage  over  this  because  they  offer  more  definite 
support.  In  Thomas's  method,  the  leather  of  the  siioe  becomes 
stretched  and  pliable,  allowing  the  foot  to  move  inside  of  the  shoe 
and  so  impairing  the  accuracy  of  the  support. 

In  the  severer  forms,  when  there  is  decided  eversion  ()\  tl)e  foot, 
a  support  holding  the  leg  is  needed.  Such  may  be  afforded  by 
means  of  steel  sole  plates,  with  an  upright  passing  on  the  outside 
of  the  leg,  with  a  supporting  strap  around  the  inner  malleolus  de- 
scribed  in  speaking  of  infantile  paralysis.     This  is  the  ordinary 


3    ~N 


Fig.  746. — Thomas'  Wedge-shaped  Heel 
for  Fiat-Foot  Shoe,  Right  Foot. 


Fig,  747. — Apph'ance  for  Fiat-Foot. 


valgus  appliance,  worn  on  the  outside  of  the  foot  with  a  leather 
support  over  the  inner  malleolus  and  secured  to  the  upright. 

Other  forms  of  apparatus  have  been  employed  depending  upon 
the  pressure  on  the  malleolus  by  a  padded  plate  attached  to  the 
uprights. 

Boots  with  stiff  counters  are  of  little  value  as  a  therapeutic  aid. 

In  very  severe  cases,  before  beginning  other  treatment,  it  may 
be  necessary  to  replace  the  foot  in  a  normal  position  and  retain  it 
there  by  a  plaster  of  Paris  bandage. 

The  plan  of  Mr.  Willet,  who  used  this  method  of  rectification  by 
plaster  bandages,'  Avas  in  the  first  instance  to  anaesthetize  the  patient 
and  put  up  the  foot  in  the  best  possible  position,  encasing  it  in  a 
firmer  plaster  bandage.  The  patient  walked  about  with  this  and  at 
intervals  of  a  few  weeks  it  was  replaced  by  other  bandages  until 

'  St.  Earth.  Hosp.  Rep.,  vol.  xviii. 


742 


ORTHOPEDIC  SURGERY. 


the  arch  of  the  foot  was  restored  and  did  not  disappear  when 
weight  was  borne  upon  it. 

When  the  foot  has  been  rectified,  one  of  the  supports  described 
above  should  be  used.  Barwell  has  used  elastic  tension  by  adhesive 
plaster  strapping  secured  under  the  arch  and  pulled  upon  by  a 
stout  rubber  cord  attached  above  to  the  leg  as  shown  in  the  figure. 

Operative  treatment  is  not  often  necessary. 

In  the  most  severe  cases  of  flat-foot,  which  are  most  likely  to 
have  been  of  congenital  origin,  Ogston  refreshes  the  astragalo- 
scaphoid  articulation,  and  nails  the  bones  together  in  a  corrected 


Fig.  750. 


Figs.  748,  749,  750. — Appliances  for  Fiat-Foot. 


position.  Stokes '  removes  a  wedge  from  the  inner  side  of  the  neck 
of  the  astragalus  to  correct  extreme  valgus. 

Weinlechner  recently  exhibited  in  Vienna  a  patient  in  whose 
case  he  had  extirpated  the  astragalus  for  severe  flat-foot.  The 
result  was  very  satisfactory. 

For  the  form  of  flat-foot  characterized  as  weak  ankles,  the  treat- 
ment should  be  similar  to  that  which  is  used  for  the  lighter  forms 
of  flat-foot.  The  custom  which  is  so  common  of  binding  the 
ankles  with  tightly-laced  shoes  in  which  a  certain  amount  of  stiff- 
ening is  placed,  is  of  course  injurious  and  founded  on  a  popular 
error.  Inasmuch  as  the  distortion  is  not  at  the  ankle  proper  but 
'Trans.  Acad.  Med.  Ire.,  1885. 


FLAT-FOOr  AND  OTIIhlK  A I'h' h'.CTIONS  Ol-    Till-:  /■  l-.l-/!'.     743 

in  the  mcdio-tarsal  articulation,  stiffcnin^^  in  the  sides  of  the  boots 
extending  from  tlie  lower  part  of  the  leg  to  the  sole,  can  have  no 
effect  in  preventing  pronation,  but  will  limit  the  circulation  of  the 
foot  if  tightly  laced  and  also  impede  the  action  of  the  muscles, 
causing  atrophy  and  preventing  proper  development  of  their 
strength. 

The  affection  should  be  regarded  as,  in  a  measure,  a  mild  degree 
of  flat-foot  and  should  be  treated  by  the  gymnastics  already  de- 
scribed; if  necessary,  the  inner  side  of  the  sole  cjf  the  foot  may  be 
built  up  or  a  sole  plate  applied. 

To  sum  up  in  brief  the  treatment  of  flat-foot,  one  would  treat 
congenital  flat  foot  in  young  children  by  gradual  rectification  by 
means  of  stiff  bandages,  and  later  by  the  use  of  an  appliance.  Se- 
vere adult  cases  of  congenital  origin  would  be  only  amenable  to 
operative  treatment.  The  milder  forms  of  acquired  flat-foot  should 
be  treated  by  gymnastics,  either  alone  or  in  connection  with  some 
rigid  support  to  the  arch  of  the  foot.  The  severer  cases  would  de- 
mand some  more  extensive  support,  as  from  a  Taylor  outside  shoe, 
while  still  more  severe  cases  should  be  treated  by  operative  means. 

Talipes  Equinus. 

As  a  congenital  deformity,  talipes  equinus  is  the  greatest  of  rari- 
ties. Cases  have  been  recorded  by  Little  and  Adams,  so  that  its 
existence  is  well  established.  As  an  acquired  deformity  it  is  very 
common,  especially  in  its  lighter  degrees. 

In  the  acquired  form,  all  degrees  are  met,  from  a  condition  in 
which  the  heel  just  clears  the  ground,  to  one  in  which  the  foot  and 
leg  are  nearly  in  a  continuous  line.  The  deformity,  in  the  lighter 
degrees,  is  one  of  less  importance  than  the  other  forms,  as  the 
weight  of  the  body  does  not  tend  to  cause  an  increase  of  the  de- 
formity, but  the  body  weight  rather  tends  to  its  correction  by 
stretching  the  tendo  Achillis  in  walking. 

A  slight  degree  of  this  affection  is  enough  to  cause  a  limp  in 
walking,  as  in  carrying  the  leg  back  at  the  end  of  the  step  the  foot 
must  be  bent  more  than  to  a  right  angle. 

The  structural  changes  in  talipes  equinus  are  slight.  In  a  large 
number  there  is  simply  a  shortening  in  the  Achilles  tendon  muscles, 
with  a  consequent  alteration  in  the  shape  or  relation  of  the  bones 
of  the  foot.  Some  cases,  however,  are  due  less  to  the  raising  of 
the  calcaneum  than  to  a  depression  of  the  head  of  the  astragalus, 
which  may  be  depressed  nearly  in  a  vertical  line,  and  the  arch  of 
the  foot  increased  by  a  strong  flexion  at  the  medio-tarsal  joint. 

The  acquired  form  of  talipes  equinus  is  usually  either  paralytic 


744 


OR THOPEDIC  S URGER Y 


or  spastic.     The  most  common  cause  of  the  former  is  infantile  par- 
alysis, after  which  the  extensor  muscles  are  left  more  or  less  im- 


FiG.  751.— Talipes  Equinus. 


Fig.  752. — Skeleton  of  Foot  in 
Talipes  Equinus. 


Fig.  753. — Talpes  Equinus. 


Fig.  754. — Talipes  Equinus. 


Fig.  755. — Talipes  Equinus  from  Infantile 
Paralysis  with  Slight  Valgus. 


paired.      In   this   there   is   less   drawing   upward   of   the   heel,   the 
deformity  occurring  mainly  in  the  fore  part   of  the  foot.     By  the 


FLAT-FOOT  ANJ)  OTIITIR  A /■'/'' /■:C770j\'S  O]'     Till-:  1'1:I-/T. 


745 


loss  of  support  of  the  muscles  of  this  portion,  the  anterior  part  of 
the  foot  falls  downward,  and  in  most  instances  slightly  inward,  so 
that  the  deformity  seems  greater  at  the  inner  border.  In  the 
severer  forms  there  is  a  marked  projection  on  the  dorsum  formed 
at  the  site  of  the  calcaneo-cuboid  and  astragalus-scaphoid  articula- 
tions. As  locomotion  occurs  only  on  the  ball  of  the  foot,  this  part 
becomes  abnormally  wide,  and  in  time  the  plantar  fascia  contracts 
and  resists  the  reduction  of  the  malposition. 

The  same  may  be  said  of  those  paralytic  cases  due  to  other 
causes  than  infantile  palsy;  such  as  injury  to  the  nerves,  etc. 

The  spastic  form  is  most  commonly  met  with  as  occurring  in 


Fig.  7s6. 


Figs.  756,  757. — Talipes  Equinus. 


Fig.  757. 


spastic  paralysis  or  after  hemiplegia.  As  this  is  due  to  the  con- 
traction of  the  muscles  of  the  tendo  Achillis,  the  position  of  the 
foot  in  this,  differs  from  that  following  paralysis.  The  heel,  in  the 
spasmodic  form,  is  drawn  upward  and  the  whole  foot  depressed  in 
consequence.  There  is,  therefore,  much  less  tendency  to  the  for- 
mation of  an  angle  in  the  medio-tarsal  or  tarso-metatarsal  joints. 

In  very  severe  cases,  the  foot  is  bent  on  itself,  so  that  the  sole  is 
directed  upward  and  backward,  and  locomotion  takes  place  on  the 
dorsum  of  the  foot. 

Another  form  often  met  with  is  a  condition  of  equinus  in  short- 
ened limbs,  as  after  recovering  from  hip  disease,  fracture,  etc. 
The  development  of  this  is  the  result  of  the  maintenance  of  the 
foot  for  a  long  time  in  a  partially  extended  position,  in  the  act  of 


746 


OR  THOPEDIC  S  URGER  F. 


walking  and  standing.  In  these  cases  it  is  a  compensatory  ar- 
rangement, inasmuch  as  it  tends  to  keep  the  pelvis  level,  and  not  to 
be  regarded  as  objectionable  except  in  its  appearance. 

The  detection  of  talipes  equinus  is  so  simple  a  matter  that  it 
scarcely  needs  description.  The  normal  foot  should  be  capable  of 
flexion  somewhat  beyond  a  right  angle,  and  any  cause  which  re- 
stricts this  flexion  is  a  degree  of  talipes  equinus. 

It  must  be  remembered  that  persistent  extension  of  the  foot  is 
at  times  a  symptom  of  caries  of  the  ankle-joint. 

Shaffer  has  described  under  the  name  of  "  non-deforming  club- 
foot "  an  affection  which  consists  of  a  condition  of  imperfect  flex- 
ion at  the  ankle  and  medio-tarsal  joints.     The  heel  can  be  placed 


Fig.  758. 


Fig.  759. 
Figs.  758,  759,  760. — Severe  Talipes  Equinus. 


Fig.  760. 


readily  upon  the  ground,  but  the  front  of  the  foot  cannot  be  raised. 
This  condition  has  also  been  described  by  Noble  Smith. 

The  condition  is  in  all  probability  an  acquired  one,  and  is  com- 
plained of  chiefly  by  young  adults  or  children.  It  is  chiefly  noticed 
by  the  patients  as  a  difficulty  in  walking  up  hill  or  any  inclination. 
The  affection  often  escapes  notice.  On  casual  inspection  but  little 
deformity  is  to  be  seen,  but  on  a  more  careful  inspection  an  in- 
crease in  the  height  of  the  plantar  arch  will  be  noticed,  so  that  the 
inner  border  of  the  foot  is  abnormally  raised  from  the  ground. 
There  is  little  or  no  adduction  of  the  tarsus  or  metatarsus,  and  the 
shortening  which  results  from  this  arching  is  entirely  on  the  inner 
side.  The  point  at  which  the  arch  is  increased  is  just  posterior  to 
the  junction  of  the  first   metatarsal  bone   with  its  first  phalanx. 


FLAT-FOOr  AND  OTHER  AFFECTIONS  OE   Till:  EEET.     747 

The  foot  cannot  usually  be  bent  up  beyond  a  right  angle,  and  in 
the  attempt  to  accomplish  this,  as  well  as  in  the  act  of  walking, 
the  great  toe  is  held  in  a  position  of  extreme  extension. 

Shaffer  classifies  non-deforming  club-foot  as  follows:  (i)  Follow- 
ing acute  poliomyelitis  anterior.  (2)  Following  simple  uncompli- 
cated malposition,  habit,  etc.  (3)  Produced  by  traumatism,  sprains, 
etc.  (4)  Found  after  acute  infectious  diseases  of  children,  espe- 
cially diphtheria  and  scarlet  fever.    (5)  Due  to  some  remote  trophic 


Fig.  761. — Non-Deforming  Club-Foot. 


Fig.  762.  Fig.  763. 

Figs.  762,  763. — Footprints  in  Normal  and  in  Non- 
Deforming  Club-Foot. 


disturbance,  as  when  sometimes  seen  associated  with  lateral  curva- 
ture. 

The  symptoms  complained  of  are  pain  in  various  parts  of  the 
foot  and  leg,  which  may  even  be  reflected  to  the  lumbar  region ; 
tenderness  is  often  present,  especially  over  the  metatarso-phalangeal 
joint  of  the  great  toe.  The  condition  is  very  often  found  associ- 
ated with  rotary  lateral  curvature. 

Treatment  of  Talipes  Equinus. — In  the  treatment  of  cases  of  tali- 
pes equinus,  whether  congenital  or  acquired,  the  choice  would  lie 
between  two  methods :  mechanical  or  operative ;  the  degree  of  de- 
formity present  being  the  deciding  factor. 


748 


ORTHOPEDIC  SURGERY. 


C^'^^s^ 


The  simplest  mechanical  method  of  the  correction  of  an  equinus 
deformity,  is  to  furnish  a  light  appliance  which  prevents  the  foot 
from  turning  to  the  outside  or  inside,  and  then  connect  to  it  two 
uprights  extending  up  the  leg  which  shall  prevent  bending  at  the 
knee.  In  walking  the  whole  weight  falls  on  the  ball  of  the  foot, 
and  the  length  of  the  foot  serves  as  a  lever  to  stretch  contraction 
of  the  tendo  Achillis.  This  method  is  naturally  only  applicable  to 
light  cases. 

The  turning  of  the  foot  to  either  side  can  be  prevented  by  the 

simple  retention  shoe,  already 
mentioned  in  the  chapter  on 
club-foot. 

Dr.  Shaffer  advises  the  use  of 
intermittent  traction  by  means 
of  a  powerful  appliance  work- 
ing by  means  of  screw  force. 

The  antero-posterior  traction 
shoe  consists  of  a  calf  band  and 
two  uprights,  with  a  heel  cup 
and  sole  plate.  Antero-poste- 
rior motion  of  the  shoe  can  be 
obtained  at  the  ankle  by  an 
endless  worm  and  screw  mov- 
ing the  whole  foot-piece,  and 
controlled  by  a  key.  At  a 
place  corresponding  to  the  me- 
dio-tarsal  joint,  the  sole  plate 
is  divided  transversely,  and  the 
two  parts,  anterior  and  poste- 
rior, are  connected  by  a  trac- 
tion-rod, with 'ratchets,  worked 
by  a  key  under  the  heel  cup. 
Two  webbing  straps  are  applied  to  the  foot :  one  over  the  as- 
tragalus, and  one  around  the  heel.  They  cross  each  other,  and 
the  ends  of  the  former  are  fastened  to  the  heel  cup,  and  the  heel 
traction-straps  are  carried  forward  to  the  anterior  end  of  the 
shoe,  and  buckled.  The  ankle-joint  of  the  shoe  is  set  to  fit  the 
deformity,  and,  by  tightening  the  straps,  the  foot  is  pulled  down 
on  to  the  shoe.  Then  loosen  the  strap  over  the  head  of  the  as- 
tragalus, to  allow  it  to  rotate.  By  the  key,  the  foot  is  brought  to 
a  right  angle.  Then  the  forward  part  of  the  sole  plate  is  separated 
from  the  other;  it  pulls  on  the  heel  traction-strap,  and  the  heel  is 
pulled  irresistibly  downward  and  forward.  Shaffer  states  that  a 
temporary  gain   of    one-eighth   to   one-fourth    of    an   inch   in    the 


Fig.  764. — Diagram  Showing  Centre  of  Motion  in 
Ankle  Joint.     (Shaffer.) 


FLAT-FOOT  AND  OTHER  AFJ'FCT/ONS  OF   77 IF.  FFF'F     749 


length  of  the  foot  is  not  unusual  after  a  single  treatment  of  fifteen 
minutes. 

In  cases  of  non-deforming  club-foot,  relief  of  symptoms  will  very 
often  at  once  follow  the  application  of  this  shoe.  In  talipes  equinus 
the  method  is  efficient  but  requires  time.  In  the  lightest  cases  the 
use  of  a  shoe  with  a  higher  heel  than  normal  relieves  the  symptoms 
without  treatment. 

A  ready  appliance  can  be  made  as  has  been  described  by  Sayre, 
by  securing  the  patient's  leg  to  a  flat  smooth  piece  of  board,  by 


Fig.  765. — Shaffer's  Appliance  for  Correcting  Equinus. 


Fig.  766. — The  Same  with  Force  Applied. 


means  of  strips  of  adhesive  plaster  from  the  sides  of  the  leg  to  the 
bottom  of  the  board.  If  this  board  is  longer  than  the  foot  and  is 
furnished  with  a  strap  secured  to  the  projecting  end  of  the  board 
and  to  a  buckle  secured  to  the  leg  by  adhesive  plaster,  stretching 
the  tendo  Achillis  can  be  accomplished  by  tightening  the  strap. 
This  method  requires  that  the  patient  be  kept  in  bed,  or  at  most 
should  go  about  on  crutches,  swinging  the  affected  leg.  More 
complicated  appliances  similar  to  those  needed  in  correction  of 
club-foot  can  be  used. 

Several  appliances  employing  the   elastic   extension   have   been 
devised.     For  use  in  this  deformity,  where  there  is  a  simple  exten- 


750 


ORTHOPEDIC  SURGERY. 


sion  of  the  foot,  and  all  that  is  required  is  the  raising  of  the  ante- 
rior portion,  they  may  be  of  service;  but  in  cases  of  deformity  of 
the  foot  itself  they  can  be  of  little  value.  They  are  open  to  the 
objection  which  have  been  made  to  all  elastic  appliances. 

In  all  appliances  of  this  sort,  the  chief  difficulty  is  to  check  the 
tendency  of  the  appliance  to  fall  away  from  the  patient's  heel. 
This  can  be  done  by  means  of  adhesive  plaster  securing  the  leg  to 
the  bottom  of  the  appliance. 

Operative  Treatment. — Tenotomy  will  be  found  of  the  greatest 
service  in  relieving  this  distortion,  and  is  indicated  in  all  except 
milder  forms  of  the  deformity,  when  it  is  important  to  save  time  or 
expense.  In  the  less  severe  cases  tenotomy  of  the  tendo  Achillis 
and  often  of  the  plantar  fascia,  when  that  contributes  to  the  de- 
formity, will  be  all  that  is  required  and  the  foot  can  be  rectified  in 


Fig.  767. — Sayre's  Apparatus  for  Correction  of 
Equinus. 


Fig.  768. — Heidenhain's  Apparatus  for 
Equinus. 


plaster  of  Paris.  Where  the  deformity  is  due  to  spastic  paralysis, 
simple  tenotomy  of  the  heel  tendon  is  sufficient ;  when  there  is  con- 
traction of  the  plantar  fascia,  that  should  be  cut  before  tenotomy 
of  the  tendo  Achillis  is  done,  as  the  contracted  heel  tendon  affords 
useful  counter-pressure  in  straightening  the  arch  of  the  foot  after 
division  of  the  fascia. 

Retention  of  the  foot  in  the  corrected  position  is  necessary  after 
operation  in  all  cases  except  those  due  to  spastic  paralysis,  other- 
wise a  relapse  is  likely  to  occur.  For  retention  of  the  foot  later, 
the  usual  form  of  club-foot  shoe,  with  the  ankle-joint  arranged  to 
stop  extension  at  a  right  angle,  will  be  found  to  be  effectual  and 
simple.  It  can  be  worn  inside  an  ordinary  shoe  and  causes  no 
disfigurement. 

In  extremely  severe  cases  a  wedge-shaped  osteotomy  of  the  tarsus 
might  be  required  for  rectification,  but  this  would  be  very  unusual. 


FLAT-FOOr  ANJ)  OTHER  AFFECTIONS  OE   Till-:  EJiJ'.T. 


751 


Taijimos  Cai-cankus. 


As  most  commonly  met,  the  affection  is  the  result  of  infantile 
paralysis,  and  the  congenital  form  is  comparatively  rare ;  as  seen  in 
connection  with  valgus  the  deformity  is  not  so  uncommon  as  it  is 
in  the  pure  form  of  calcaneus.  A  position  of  the  foot  simulating 
talipes  calcaneus  is  noticed  in  caries  of  the  ankle-joint  in  many 
cases. 

Treatuioit. — The  treatment  of  congenital  simi)lc  calcaneus   sel- 
dom requires  more  than  manipulation  on   the  part  of  the  parents, 
practised   daily  until  the  deformity  is  overcome   or  is  manifestly 
not  improving.     In  extreme  cases  only  will  tenotomy 
be  required.     When  the  foot  has  been  reduced  to  the 
normal  position,  and  the  motion  extended  to  the  nor- 
mal limits,  a  retention  shoe  may  be  applied ;  bi 
slight  cases  this  is  not  necessary. 


''s^ 


1^^ 
%®>^ 


Fig.  769. — Talipes  Calcaneus. 


Fig.  770.  Fig.  771. 

Figs.  770,  771. — Appliances  for  Talipes  Calcaneus. 


For  retention,  a  steel  sole  plate  and  upright,  with  the  strap  at 
the  ankle-joint  so  as  to  prevent  flexion  beyond  a  right  angle,  is  of 
value.     Dr.  Judson  '  advocates  the  use  of  a  similar  brace. 

Elastic  tension  has  been  used  as  a  correcting  as  well  as  a  reten- 
tion appliance,  the  principle  being  in  application  the  reverse  of 
the  one  for  equinus. 

Shortening  of  the  tendo  Achillis  by  means  of  operative  interfer- 
ence has  been  done  as  a  means  of  correction  of  talipes  calcaneus, 
and  is  described  in  speaking  of  infantile  paralysis. 


Med.  Record,  May  i6th,  18S5. 


752 


ORTHOPEDIC  SURGERY. 


Pes  Cavus,  also  known  as  Pes  Arcuatus. 

In  this  deformity  the  anterior  part  of  the  foot  is  drawn  backward 
and  the  arch  increased.     All  degrees  of  severity  are  found,  even  to 

a  condition  in  which  the  ball  of  the  foot 
and  heel  are  in  contact ;  and  the  arch 
of  the  foot  is  converted  into  a  deep  sul- 
cus.     In    an    exaggerated    degree    it    is 


Fig.  772. — Dissection  in  Pes  Cavus, 
after  Nicoladoni. 


Fig.  773. — Pes  Cavus. 


Fig.  774.  Chinese  Lady's  Foot. 


the  condition  of  the  feet  of  high-caste  Chinese  women.  This  form 
is  in  reality  a  variety  of  the  calcaneus,  to  which  the  cavus  has  been 
added. 

Three  forms  of  pes  cavus  are  recognized.     The  first  is  due  to  the 
contraction  of  the  peroneus  longus;    and  the  resulting  deformity 


■BBSBF^V^t,^^  /,  j|^^^ 

HHwUp  ^'^    _^-     •*  -JMHW 

IHIflBr       ^  .^Hb   *%  vj^^H 

H'l^^^' 

HHHi^^%  p*  l^^HH^H^^B 

^^m 

Hi^^HH 

Fig.  775. — Diagram  of  Position  of  Bones  in  Chinese  Lady's  Foot. 


Fig.  776. — Paralytic  Pes  Cavus. 


is  in  consequence  of  the  approximation  of  its  insertion  and  the 
heel.  The  second  variety  is  the  result  of  paralysis  of  the  gastroc- 
nemius and  soleus  muscles.  The  sole  of  the  foot  is  lowered,  and 
by  the  action  of  the  long  flexors  on  the  anterior  part,  a  cavus  foot 


FLAT-I'OOT  AND  OTJlhlR  AJ'-I'l'lC'I'IONS  ()/■■    THE  r'EET. 


753 


is  developed.  There  may  be  complie.ited  with  this  a  varus  or 
valgus  distortion. 

The  third  form  may  be  acquired,  but  is  usually  congenital.  It 
has  been  called  by  Duchenne  "  Griffe-pied-creux."  The  condition 
results  from  a  marked  depression  of  the  heads  of  the  metatarsal 
bones  with  a  forced  extension  of  the  first  phalanges  and  a  flexion 
of  the  last.  The  origin  of  the  affection  is  in  a  paralysis  of  the  in- 
terossei  and  lumbricoid  muscles,  and  of  those  muscles  which  are 
inserted  into  the  sesamoid  bones  of  the  great  toe. 

Treatment. — It  is  difificult  to  correct  the  deformity  of  pes  cavus 
by  mechanical  appliances;  the  common  form  of  these  consists  in 
a  steel  sole  plate  with  a  constricting  band  over  the  head  of  the  as- 


Fin.  777.  Fig.  778. 

Figs.  777,  77S.— Bigg's  Appliance  for  Pes  Cavus. 

tragalus.  The  apparatus  devised  by  Mr.  Bigg  is  said  by  Schreiber 
to  be  ef^cient.  It  is  shown  in  the  figure  and  can  be  seen  to  consist 
of  a  curved  steel  sole  plate  Avhich  can  be  straightened  by  a  screw 
in  its  bottom.  The  foot  is  secured  to  this  in  the  curved  position 
and  the  sole  plate  straightened. 

An  ordinary  steel  sole  plate  made  from  a  cast  of  the  corrected 
foot  and  inserted  in  the  shoe  is  of  assistance. 

Deformities  of  the  Toes. 


Hallux  Valgus. — The  most  common  of  the  deformities  of  the 
toes  is  an  inward  deviation  of  the  great  toe,  hallux  valgus.  This  is 
almost  exclusively  an  affection  of  adult  life,  but  is  occasionally 
seen  in  adolescence.  In  old  age  it  is  often  found  in  conjunction 
with  chronic  rheumatoid  arthritis,  or  with  bunion.  So  common  is 
a  slight  degree  of  the  deformity  that  it  is  regarded  b}'  some  boot 
makers  as  the  normal  shape  of  the  foot.  The  deformity  is  entirely 
the  result  of  improper  shoes,  and  bare-footed  people  never  suffer 
from  it. 


754 


OR  THOPEDIC  S  UR  GER  Y. 


This,  however,  is  not  necessarily  the  result  of  tight  shoes,  for  the 
deformity  may  come  in  people  who  have  only  worn  comparatively 
loose  ones. 

The  upper  leather  of  shoes  being  more  yielding  than  the  sole, 
it  stretches  under  the  pressure  of  use,  or  is  stretched  to  avoid 
pressure  upon  the  metatarso-phalangeal  articulation.  The  boot  is 
not  stretched  at  its  extreme  end,  and  it  inevitably  becomes,  in  a 
degree,  conical  in  shape  on  this  account,  being  broader  across  the 
ball  of  the  foot  than  at  the  tip  end.  In  the  act  of  walking  the  foot 
necessarily  slips  inside  of  the  boot  to  a  certain  extent,  and  if  the 
shoe  slips  backward  and  the  foot  forward,  a  certain  amount  of 
pressure  will  come  upon  the  inner  side  of  the  end  of  the  great  toe.. 

This  deformity  may  also  be  occasioned 
by  short  boots  and  the  ordinary  pointed 
toe  boots,  or  any  boot  which  does  not 
give  more  room  for  lateral  spreading  of 
the  toes  than  at  the  metatarso-phalan- 
geal articulation,  would  necessarily  give 
rise  to  the  trouble. 

When  this  condition  con- 
tinues for  any  length  of 
time,  alteration  of  the  bones 
of  the  joint  takes  place. 
The  head  of  the  metatarsal 
is  partly  uncovered  as  the 

Figs.  779,  780, 78i.-Hallux  Valgus.  phalanx     is     pUshcd     tO     the 

outer  side,  and  the  head  may  become  enlarged  from  growth  of  the 
pain  due  to  periosteal  irritation.  The  skin  over  this  prominent 
bone  grows  thick  and  a  bursa  forms  on  the  outer  edge.  This  may 
become  inflamed,  giving  rise  to  an  extensive  cellulitis,  which  may 
include  the  whole  dorsum  of  the  foot,  which  may  suppurate  and 
cause  necrosis  of  the  bone.  This  latter  termination  is,  however, 
very  rare  and  only  occurs  in  neglected  cases. 

Bunion  is  the  name  applied  to  an  inflammation  of  a  bursa  which 
forms  on  the  inside  of  the  metatarso-phalangeal  articulation,  and 
in  some  cases  an  inflammation  of  that  joint  itself.  It  occurs  most 
often  in  connection  with  hallux  valgus. 

The  symptoms  due  to  hallux  valgus  in  the  non-inflammatory 
stages  are  chiefly  those  resulting  from  the  alteration  of  the  shape 
of  the  foot.  In  aggravated  cases  a  peculiar  gait  is  noticeable,  the 
foot  is  thrown  out  and  there  is  loss  of  elasticity  in  the  gait.  There 
may  be  pain,  and  in  the  severe  cases  extreme  pain  and  difificulty  in 
walking,  which  is  usually  attributed  by  the  patient  to  gout.     On 


Fig.  780. 


Fig.  781. 


FLAT-FOOT  AN  J)  OTJII'IR  A /'/•JCCTIONS  O/'    Till-:  /•/•:/:  Z'.     755 


examin.ition  sensitiveness  of  the  metatarso-plialan^^eal  joint  is  de- 
tected on  pressure. 

Thc  treatment  of  this  affection  in  the  acute  stages  is  the  treat- 
ment of  all  acute  local  inflammation,  and  tiie  application  of  prjul- 
tices  or  of  ice  combined  with  rest  to  the  joint  will  usually  allay  the 
inflammatory  symptoms. 

The  treatment  of  the  distortion  is,  in  children,  the  wearing  of  a 
splint  of  hard  rubber,  or  gutta  percha,  or  stiffened  pasteboard,  and 
binding  the  toe  to  it  so  as  to  pull  it  inward.  In  old  cases  no  at- 
tempt can  be  made  successfully  to  correct  this  distortion,  except 
the  Hueter's  operation  of  removal  of  the  head  of  the  phalanx  and 
metacarpal  bone.     This  can   be  done  with  an  osteotome  or  a  thin 

watch-spring  saw,  and  the  operation 
is  attended  by  little  risk  even  in  old 
people,  and  gives  complete  relief.     In 


Fig.  782. — Bigg's  Appliance  for  the  Correction 
of  Hallux  Valgus. 


Fig.  783. — Soles  of  Shoes  for  Cases  with 
Hallux  Valgus. 


ordinary  cases  it  is  simply  necessary  to  see  that  proper  shoes 
are  made  on  the  "  Waukenphast"  pattern,  or  on  that  of  the  Chinese 
shoe.  Bunions  when  inflamed  are  to  be  treated  by  rest,  and  pro- 
tection from  pressure  afforded  by  bunion  plasters.  Sometimes  it 
is  necessary,  however,  to  dissect  out  the  bursal  sac,  and  where  cel- 
lulitis is  present  and  suppuration,  an  incision  is  necessary. 

In  the  subacute  condition  the  projecting  head  of  the  bone 
should  be  protected  by  felt,  so  that  no  pressure  can  fall  upon  the 
head  of  the  bone,  the  common  bunion  shields,  if  of  sufficient  thick- 
ness, serving  excellently  for  the  purpose. 

Where  they  cannot  be  procured,  Sadler's  felt  can  be  applied,  a 
hole  being  cut  over  the  projecting  head  of  the  bone,  and  shoes 
should  be  made  so  as  to  exert  no  pressure  upon  the  inner  side  of 
the  great  toe.  The  use  of  properly  made  shoes  is  essential  for 
after-treatment,  and  also  for  the  prevention  of  the  increase  or 
recurrence  of  the  deformity. 


756 


OR THOFEDIC  S URGER Y 


Shoes  should  be  so  constructed  that  no  pressure  is  possible  which 
will  force  the  great  toe  to  the  outer  side.  Pointed  shoes  should  be 
avoided.  The  sole  of  the  shoe  should  be  not  only  as  broad  as  the 
sole  of  the  foot,  but  in  cases  where  there  is  a  tendency  to  this 
deformity,  there  should  be  room  made  in  the  front  of  the  shoe  for 
the  first  metatarso-phalangeal  joint  of  the  large  toe  to  move  to 
the  inside. 

Hallux  Varus. 

This  deformity  is  not  a  common  one,  and  is  known  also  as  in- 
toe  or  pigeon  toe.  It  is  rarely  of  any  importance,  and  although 
ordinarily  congenital  in  origin,  it  may  occasionally  be  seen  in 
young  children  with  flat-foot,  and  the  writers  have  observed  it 
in  a  few  cases  of  over-corrected  club-foot  where  a  valgus  has 
resulted. 

This  distortion  does  not  require  treatment,  and  the  use  of  ordi- 
nary shoes  is  sufficient  to  correct  the  deformity.  In  one  instance 
the  writers  applied  with  success  a  light  padded  sole  plate  so  con- 
structed as  to  press  upon  the  inner  side  of  the  great  toe. 

Hallux  Rigidus. 

This  deformity  is  sometimes  seen  in  adolescents,  consisting  of 
an  ankylosis  at  the  metatarso-phalangeal  joint  of  the  great  toe. 
The  deformity  consists  of  a  forced  flexion  of  the  proximal  phalanx 
of  the  great  toe  through  30°  to  60°,  with  extension  of  the  second 
phalanx,  as  described  by  Davies  Colley. 

The  symptoms  vary  with  the  stage  of  the  disease.  Early  there 
may  be  slight  pain  over  the  joint  and  painful  motion,  but  they 
rarely  come  to  the  surgeon's  notice  at  this  time.  Later  there  is 
swelling  over  the  joint,  with  rawness  and  tenderness,  and  perhaps 
an  enlargement  of  the  bone  itself.  If  the  disease  progresses,  the 
joint  becomes  ankylosed  in  the  distorted  position  and  the  fascia  and 
muscles  contract,  which  still  more  firmly  secures  the  deformity  in' 
position.     The  usual  atrophy  after  ankylosis  often  occurs  here. 

The  condition  is  often  associated  with  flat-foot,  and  although 
Colley,  the  original  writer  upon  this  subject,  attributed  but  little 
influence  to  it  as  a  causative  factor,  later  writers  have  been  more 
inclined  to  consider  the  connection  of  the  two  as  important;  the 
rigid  condition  of  the  toe  being  probably  the  result  of  a  subacute 
arthritis  of  the  metatarso-phalangeal  joint.  Ill-fitting  shoes  also 
have  an  influence  in  causing  the  distortion.  At  times  it  arises 
from  an  injury. 

The  treatment  in   the   early  stages  will   consist  in   removing  the 


J'LAT-I'OOT  AND  OTIII'lR  A /''/■'/CCT/O/VS  ()/■■   TI/F.   hl:l-:r.     757 

exciting  cause,  and  properly  sLipptjrting  llie  for^t.  If  there  is  pain, 
with  signs  of  inflammation,  rest  witli  local  apijlications  is  indicated, 
and  later  protection  by  splints  with  sup]jort  of  the  arch  of  the  foot. 
In  inveterate  cases  excision  of  the  joint  may  be  necessary. 

Hammi:r  Toi'-.. 

This  deformity  consists  of  a  clawJike  contraction  of  one  of  the 
toes,  usually  the  second  or  third.  The  condition  is  one  of  flexion 
of  the  first  phalanx,  with  extension  of  the  second,  so  that  the 
pressure  on  the  ground  is  sustained  by  the  proximal  phalanx. 
Over  the  upward  projecting  joint  there  is  usually  a  callosity,  which 
may  cause  considerable  annoyance. 

The  origin  of  the  deformity  is  not  well  understood,  but  in  some 
cases  is  supposed  to  be  caused  by  short  boots.     Mr.  Adams  thinks 


\  - 


-Hammer  Toe. 


Fig.  785. — Hammer  Toe  seen  in  Section. 


it  is  not  the  result  of  short  boots,  but  considers  it  essentially 
hereditary. 

In  the  slight  degrees  and  early  stages  of  the  deformity,  the 
patient  experiences  but  little  discomfort,  and  such  cases  are  not, 
therefore,  commonly  seen  by  the  surgeon  in  this  stage.  Later, 
however,  locomotion  becomes  difficult  and  painful. 

In  children  and  adolescents  the  deformity  can  generally  be  cor- 
rected by  simple  mechanical  treatment  in  all  but  the  severest  cases. 
The  toe  should  be  bandaged  or  strapped  to  a  rigid  plantar  splint, 
which  can  easily  be  made  of  tin.  The  strapping  should  be  renewed 
often  enough  to  keep  the  toe  extended.  In  very  severe  cases  and 
in  adults  the  deformity  is  best  remedied  by  amputation  at  the 
metatarso-phalangeal  articulation,  in  children  it  can  be  corrected 
by  subcutaneous  section  of  the  contracted  fasciae,  forcible  straight- 
ening, and  fixation  in  a  straight  position  b}'  means  of  splints  and 
adhesive  plaster. 

Amputation  at  the  inter-phalangeal  joint  is  of  no  use,  as  the  prox- 
imal phalanx  remains  still  elevated,  so  that  the  only  operative  pro- 
cedure worth}^  of  consideration  is  amputation  at  the  metatarso- 
phalangeal articulation.      After  correction  by  mechanical    means 


758 


OR  THOPEDIC  S  UR  G  ER  V 


the  deformity  shows  a  tendency  to  recontract  and  must  be  care- 
fully Avatched. 

Other  operations  than  amputation  have  been  recently  advocated 
for  the  relief  of  this  condition.  Adams  divides  the  external  lateral 
ligaments  subcutaneously,  and  extending  the  toe  keeps  it  on  a 
metal  splint  for  three  or  four  weeks.  Petersen  removes  the  soft 
and  tendinous  structures  from  the  under  side  of  the  affected  toe. 
Terrier  makes  a  longitudinal  incision  along  the  dorsum  of  the  toe 
and  removes  with  bone  forceps  the  ends  of  the  phalanges  which 
form  the  affected  joint,  and  then  cutting  away  the  bursa  and  the 
callus  from  the  top  the  toe  is  dressed  in  the  extended  position.  In 
eight  cases  he  has  also  done  cuneiform  osteotomy  with  perfectly 
satisfactory  results. 

Deviation  of  the  Small  Toes. 

The  other  toes  may  be  displaced  from  being  crowded  together, 
either  in  such  a  way  that  one  toe  is  forced  to  lie  upon  or  over  the 
others.  This  is  almost  invariably  an  acquired  affection,, but  rarely 
it  may  be  seen  in  the  feet  of  infants.  This  crowding  may  also 
cause  the  toe  to  double  on  itself,  in  such  a  way  that  the  head 
touches  the  ground  at  the  end  of  the  nail,  instead  of  on  the  pulp. 
This  forced  flexion  may  become  so  severe  as  to  give  much  annoy- 
ance, causing  an  ulceration  at  the  end  of  the  toe,  and  an  inflamed 
bursa  on  the  dorsum.  This  position  of  the  toes  may  also  be  the 
result  of  unequal  power  of  the  antagonistic  muscles. 

In  children  and  in  light  cases,  the  deformity  may  often  be  cor- 
rected by  replacing  the  toe  and  securing  it  in  position  by  winding 
adhesive  plaster  about  it  and  a  contiguous  toe,  which  may  serve  as 
a  splint,  and  attention  to  proper  shoes,  viz.,  Indian  moccasins,  can- 
vas shoes,  and  tennis  shoes,  being  sufficiently  serviceable,  sightly, 
and  loose  for  house  or  summer  wear. 

In  adults  and  in  pronounced  cases,  amputation  is  the  only  satis- 
factory method  of  treatment. 

A  contracted  position  of  several  toes  is  sometimes  seen,  either  as  a 
result  of  improper  shoeing  or  as  a  sequel  to  a  previous  paralysis  of 
some  of  the  muscles  of  the  foot.  The  tendons  and  fascise  will  be 
found  shortened,  as  is  seen  in  Dupuytren's  contraction  of  the 
hand. 

This  deformity  is  to  be  treated  in  the  same  way  as  the  contrac- 
tion of  one  toe.  In  this,  as  in  all  similar  affections  of  the  toes, 
properly  made  shoes  are  necessary  to  prevent  relapse  or  to  secure 
permanent  recovery.  Digitated  stockings  or  stocking  splints  for 
freer  motion  at  the  great  toe  are  sometimes  of  assistance. 


FLAT-FOOT  AM)  OTJ/Fh'  AF/'KCT/OA'S  OF   THE  IllET.     -jz^c) 

It  is  safe  to  say  that  in  obstinate  cases,  all  contracted  fasci,'e  or 
tendons  sliould  be  freely  divided. 

The  various  joints  of  the  toes  may  bec(jrne  inflamed  and  ankylo- 
sis of  the  metatarso-plialangeal  articulation' may  occur;  for  the 
former,  Thomas'  shoe,  which  keeps  the  toe  at  rest,  is  of  use.  It  has 
been  described  in  speaking  of  the  diseases  of  tiie  ankle-  and  foot- 
joints. 

Caries  of  the  diaphyses  of  the  metatarsals  is  not  uncommon  in 
children. 

Painful  Affection  of  tiif  Foot. 

Morton,  of  Philadelphia,  has  described  what  he  terms  a  painful 
affection  of  the  foot  which  consists  of  a  severe  neuralgia  extending 
from  the  head  of  the  fourth  metatarsal  bone  at  its  junction  with 
the  fifth.  The  pain  may  be  intense  at  times.  The  affection  is 
sometimes  caused  by  a  slight  twist  of  the  foot,  or  it  may  come  on 
without  assignable  cause.  It  affects  mostly  young  adults,  and  is 
aggravated  by  squeezing  the  foot  or  any  lateral  pressure.  It  may 
be  so  severe  that  the  patient  is  unable  for  a  time  to  stand  upon  it, 
and  the  pain  may  extend  the  whole  length  of  the  limb ;  it  may  be 
paroxysmal,  no  redness  or  swelling  is  seen,  but  localized  tenderness 
may  be  felt  on  deep  pressure.  The  affection  has  been  attributed 
by  Morton  to  the  pinching  of  the  nerve  between  the  fourth  and 
fifth  metatarsal  bones.  Owing  to  the  anatomical  arrangement  of 
the  bones  the  interosseous  nerve  between  these  bones  is  less  pro- 
tected from  the  pressure  of  the  head  of  the  fifth  metatarsal  bone 
than  the  other  interosseous  nerves.  The  affection  may  be  acute, 
subacute,  or  chronic.  In  the  acute  form  locomotion  is  absolutely 
impossible.  In  the  subacute  form  at  times  the  pain  may  be  in- 
tense, but  it  may  subside  and  become  acute  wathout  known  cause. 
This  same  affection  has  been  termed  anterior-metatarsalgia  by  a 
French  surgeon.  Tenderness  is  localized  and  is  severe  over  the 
distal  ends  of  the  fourth  and  fifth  metatarsals. 

The  affection  can  be  distinguished  from  fiat-foot  by  the  localiza- 
tion of  the  pain  and  tenderness  in  the  place  specified,  b}-  its  sud- 
den onset,  and  by  the  fact  that  the  arch  of  the  foot  is  intact,  unless 
fiat-foot  is  also  present. 

The  affection  is  slow  to  improve  and  is  likely  to  be  acute  for 
several  daj's,  and  possibly  no  benefit  may  be  received  from  the 
treatment  at  first.  It  may  continue  for  a  long  time  in  a  subacute 
condition,  and  thus  be  the  source  of  much  discomfort,  and  the 
prognosis  should,  therefore,  be  very  guarded  as  to  the  time  which 
the  affection  will  last,  also  as  to  the  relief  which  can  be  expected 
to  follow  treatment. 


760 


OR  THOPEDIC  S  UR  GER 1  \ 


The  treatment  recommended  by  Dr.  Morton  has  been,  in  se- 
vere and  long-continued  cases,  the  excision  of  the  head  of  the 
fourth  metatarsal,  but  in  milder  cases,  tight  compression  by  a 
flannel  bandage,  and  rest.  In  a  number  of  cases  which  have  been 
observed  by  the  writers,  radical  measures  were  not  necessary,  and 
in  the  more  acute  stages  the  application  of  ice  or  the  alternate 
application  of  hot  water  and  ice  with  the  use  of  menthol,  or  of 
oleates  of  morphia  and  atropia,  sufificed  to  allay  the  symptoms. 
The  foot  should  not  be  bound  by  any  shoe,  and  walking  should  be 
done  only  in  loose  canvas  slippers  or  in  a  rubber  over-shoe.  After 
the  complete  subsidence  of  all  symptoms,  the  treatment  lasting  for 
perhaps  a  month,  shoes  should  be  made  so  broad  that  no  lateral 
pressure  can  fall  either  upon  the  toes  or  upon  the  heads  of  the 
metatarsal  bones.  With  properly  constructed  shoes,  patients  have 
been  able  to  avoid  operations  in  a  large  number  of  cases.  Thick 
soles  should  be  worn. 

Tenosynovitis  of  the  tendo  Achillis  is  occasionally  seen,  and  also 
the  same  affection  of  the  extensor  tendons  due  to  pressure  of  the 
shoe  lacing.  They  have  no  special  characteristics,  and  no  more 
significance  than  a  similar  condition  situated  elsewhere. 

Minor  Affections. 

Dorsal  contraction  may  follow  cicatrices  from  loss  of  substance, 
and  frequently  the  small  toe  will  be  found  extended  at  the  meta- 
tarso-phalangeal  articulation  and  lying  obliquely  upon  the  other 
toes.  This  may  result  from  pressure  of  the  shoes  and  also  from 
other  causes.  Sometimes  this  follows  a  contraction  of  the  tendon 
secondary  to  the  inflammation  of  the  metatarso-phalangeal  joint. 

All  the  extensor  tendons  can  be  divided  and  the  toes  fixed  in  an 
exaggerated  flexed  position,  the  patients  being  then  furnished  with 
shoes  of  which  the  inner  sole  reaches  only  to  the  head  of  the 
metatarsal  bones,  and  the  upper  presses  the  toes  downward. 
Plantar  contraction  is  less  common. 

A  flexed  contraction  of  the  second  toe  alone  caused  by  narrow 
shoes  is  not  so  very  uncommon,  and  cases  of  congenital  distortion 
of  this  sort  have  been  described. 

Mechanics  of  Standing. — Beely'  believes  that  in  standing  the 
points  of  the  foot  which  bear  the  weight,  are,  when  both  feet  are 
in  use,  the  heads  of  the  second  and  third  metatarsal  bones  and  the 
OS  calcis.  When  one  foot  alone  is  in  use,  the  tuberosity  of  the  fifth 
metatarsal  shares  with  the  other  bones  the  weight  of  the  body. 

'  Arch.  f.  klin.  Chir.,  1882,  Bd.  27,  Heft  2. 


CHAPTER    XXV. 

FUNCTIONAL   AFFECTIONS    OF    THE    SPINE   AND 

LIMBS. 

Definition. — Etiology. —  Frequency. — Occurrence. — Symptoms. —  Spine. — Hip. 
— Knee. — Diagnosis. — Prognosis. — Treatment. 

Functional  Affections. 

Functional  disorders  of  this  class  are  usually  termed  hysterical, 
and  are  also  spoken  of  as  neuro-mimetic,  but  both  terms  are  mislead- 
ing. The  first  by  common  usage  has  become  almost  an  expression 
of  opprobrium  and  the  second  by  its  derivation  suggests  mimicry. 
The  fact,  however,  is  that  these  cases  may  exist  not  only  without 
deceit,  but  without  any  manifestation  of  imitation,  intentional  or 
unconscious. 

In  fact  the  disorders  may  be  dependent  upon  a  disturbed  nervous 
condition,  perhaps  due  to  a  disordered  blood  supply,  brought  about 
by  nervous  exhaustion  from  over-growth,  from  disease,  or  from 
nerve  strain.  They  are  here  termed  functional,  because  there  is  no 
evidence,  clinical  or  pathological,  of  organic  disease. 

It  is  ordinarily  supposed  that  these  disorders  are  seen  in  persons 
of  an  excitable  emotional  temperament.  Such  is  usually  the  case, 
but  exceptionally  the  most  aggravated  type  of  functional  affections 
may  be  seen  in  persons  of  calm  and  composed  demeanor  manifest- 
ing no  exaggeration  in  statement  or  manner. 

By  far  the  greater  number  of  those  affected  are  women,  but  men 
occasionally  present  clearly  marked  cases  of  these  affections. 

The  manifestations  of  this  nervous  disorder  which  will  be  consid- 
ered here,  are  the  affections  of  this  class  involving  the  spine,  hip, 
knee,  and  ankle,  although  the  other  joints  can  hardly  be  considered 
exempt. 

It  is  extremely  difificult  for  a  surgeon  not  learned  as  a  neurol- 
ogist or  alienist  to  understand  the  nature  of  functional  affections. 
The  surgeon's  training  leads  him  to  regard  as  of  slight  importance 
whatever  has  no  pathological  basis  and  no  tangible  objective  real- 
ity, but  it  is  to  be  borne  in  mind  that  in  all  these  cases  an  undis- 
covered cause  in  all  probability  exists,  as  definite  and  undiscoverable 
as  the  nerve  changes  in  tetanus  or  hydrophobia. 


762  ORTHOPEDIC  SURGERY. 

The  condition  of  impairment  of  nervous  resistance  to  pain  is  seen 
in  the  dentist's  chair  after  several  hours  of  suffering,  on  the  operat- 
ijig  table  when  no  anaesthetics  are  used,  and  sometimes  in  the  re- 
covery from  anaesthesia  or  from  intoxication.  After  prolonged 
extreme  pain  all  individuals  may  become  hysterical.  The  sound 
in  ■k  telephone  is  louder  if  the  receiver  is  more  sensitive,  and  in 
functional  affections  slight  peripheral  irritation  usually  unnoticed 
will  produce  uncommon  mental  impression  if  the  recording  nerve 
centres  have  become  abnormally  sensitive. 

The  concentration  of  the  attention  upon  the  affected  part  is 
another  most  powerful  factor  in  producing  and  perpetuating  the 
phenomena  of  functional  joint  disease.  The  familiar  experiment 
of  thinking  fixedly  of  one  finger  serves  to  bring  out  a  series  of 
sensations  in  it  which  are  not  present  in  the  other  fingers,  and  illus- 
trates as  well  as  anything  can  do  the  power  which  concentrated 
attention  possesses. 

Etiology. — A  study  of  the  etiology  of  this  class  is  disappointing. 
They  belong  to  a  large  group  of  disorders  of  the  nervous  system, 
which  present  an  interesting  puzzle  as  to  the  nature  of  the  causa- 
tion. As  a  predisposing  influence,  an  emotional  temperament, 
which  enters  largely  into  the  exaggerated  statement  of  all  subjec- 
tive symptoms,  must  be  considered  in  all  cases.  The  influence  of 
home  training  and  discipline  in  the  development  of  this  tempera- 
ment is  important,  as  well  as  is  heredity.  Persons  broken  down  in 
health  by  suffering  or  chronic  disease,  become  naturally  in  time  in- 
capable of  bearing  pain,  and  the  statement  of  such  patients  is  ex- 
aggerated and  the  endurance  lessened. 

This  condition  of  hyper-sensitiveness  is  sometimes  to  be  seen  in 
young  girls,  about  the  time  of  puberty,  and  in  elderly  women  at 
the  time  of  the  menopause,  rarely  in  young  children.  Women  in 
young  and  middle  adult  life  are  the  m.ost  frequent  sufferers.  How 
far  sexual  irritation  enters  into  these  cases  as  a  causative  influence 
cannot  be  said  with  certainty,  but  in  some  cases  it  appears  to  be 
one  of  the  disturbing  factors  which  make  up  the  disease. 

The  statement  cannot  be  too  strongly  made  that,  although  these 
affections  are  seen  mostly  in  young  women  at  or  after  puberty,  it 
must  not  be  overlooked  that  they  occasionally  occur  in  young  chil- 
dren, in  boys,  and  also  in  men.  Such  cases  are  not  common,  but 
their  existence  is  too  well  established  to  require  further  statement. 

Another  fact  which  cannot  be  too  strongly  stated  is  that  func- 
tional symptoms  may  be  present  when  there  is  no  evidence  of 
mimicry  or  deceit,  and  sometimes  when  there  is  no  evidence  of  ex- 
aggeration or  emotional  excitement. 

Occurrence. — The  frequency  of  these  affections  is  not  generally 


FUNCTIONAL  AJ'/'/CCT/ONS  O/'  Till':  SI'lNI-l  ANP  LJM/iS.     7O3 

recognized,  l^rodie  made  a  surprising  assertion,  which  ICsmarch 
indorsed,  which  was  as  follows:  "  I  do  not  hesitate  to  declare  that 
among  the  higher  classes  of  society  at  least  four-fifths  cjf  the  female 
patients  who  are  commonly  supposed  to  labor  under  disease  of  the 
joints,  labor  under  hysteria  and  nothing  else."  This  statement 
seems  an  extreme  one,  but  nevertheless  it  may  well  be  used  to  put 
the  surgeon  on  his  guard  in  forming  a  diagncjsis  in  cases  of  doubt. 

With  regard  to  the  prevalence  of  functional  joint  affections  in 
the  lower  classes,  Skey  wrote  that  it  was  common  among  them,  and 
he  added :  "  In  reference  to  spinal  affections  in  young  persons,  I 
unhesitatingly  assert  that  the  real  disease  is  not  found  in  a  greater 
proportion  than  one  case  in  twenty — and  even  this  is  a  liberal 
allotment."  Shaffer  '  says :  "  My  own  experience  convinces  me  that 
neuro-mimetic  joints  and  spines,  and  more  particularly  the  latter, 
are  very  frequent  both  in  the  upper  and  lower  classes,  and  especially 
at  that  age  when  hysteria  is  most  likely  to  develop." 

Why  a  disturbance  of  the  nervous  centres  should  result  in  the 
manifestation  of  a  group  of  symptoms  so  closely  resembling  those 
of  serious  bone  disease,  is  but  one  of  the  many  phases  of  this  dis- 
order which  remain  unexplained.  The  same  may  be  said  of  the 
direction  of  these  symptoms  to  any  particular  joint;  except  that 
traumatism  is  iii  many  cases  the  cause  which  determines  the  con- 
centration of  the  attention  upon  some  one  joint. 

The  direct  exciting  cause  of  the  appearance  of  this  disease  is  fre- 
quently not  discovered,  and  is  then  usually  set  down  under  the 
broad  head  of  idiopathic. 

Symptovis. — As  a  rule  these  affections  begin  gradually,  but  occa- 
sionally cases  may  be  seen  following  trauma.  Again  they  may  be 
the  outcome  of  a  protracted  convalescence  from  some  joint  injury. 
The  symptoms  presented  may  not  be  characteristic  of  this  disorder, 
except  that  they  are  usually  much  exaggerated  and  out  of  propor- 
tion to  the  local  signs.  There  is  usually  a  condition  of  hyper- 
sesthesia,  especially  of  the  skin,  which  manifests  itself  most  clearly 
when  any  manipulation  of  the  affected  part  is  attempted.  Although 
this  is  a  very  important  factor  in  the  determination  of  this  class  of 
affections,  the  absence  of  this  hyper^esthesia  must  not  be  taken  as 
sufificient  evidence  to  exclude  the  disease.  Another  characteristic 
feature  of  these  disorders  is  the  fact  that  the  objective  signs  vary 
from  time  to  time. 

Unfortunately  organic  a'nd  functional  disease  are  at  times  asso- 
ciated. A  young  woman  with  hip  disease  of  a  mild  character  will 
sometimes  so  exaggerate  and  emphasize  her  symptoms  that  the 
case  may  appear  to  be  of  the  most  acute  sort,  but  careful  exami- 

'  Shaffer:  "The  Hysterical  Element  in  Orthopedic  Surgery,"  iSSo,  p.  6. 


764 


ORTHOPEDIC  SURGERY. 


nation  will  perhaps  show  that  the  disease  is  convalescent  and  that 
the  real  condition  is  very  favorable.  This  can  only  be  detected  by 
a  careful  examination  showing  that  the  muscular  stiffness  varies 
much  with  the  attention  of  the  patient  and  that  much  pain  is  at- 
tributed to  the  slightest  manipulation  which  can  easily  be  per- 
formed without  suffering  or  muscular  spasm  when  the  attention  of 
the  patient  is  diverted,  while  the  muscular  rigidity  of  chronic  joint 
disease  is  a  constant  and  not  a  variable  resistance  to  passive  manip- 
ulation. 

Atrophy  may  be  considerable,  but  it  is  not  greater  than  can  be 
accounted  for  by  disuse.  It  must  be  remembered,  however,  that 
this  wasting  may  take  place  to  a  marked  degree,  but  it  differs  very 
decidedly  in  amount  from  the  extreme  atrophy  which  is  seen  in 
real  joint  lesions. 

Distortions  of  the  affected  limbs  have  nothing  chdracteristic 
about  them,  except  that  they  may  follow  the  malpositions  of  the 
limb  which  occur  in  real  joint  disease.  The  hysterical  knee-joint 
is  often  flexed,  the  hip  may  be  flexed  and  perhaps  adducted  or 
abducted. 

In  short  the  symptoms  of  functional  joint  disease  have  one  dis- 
tinctive characteristic,  they  are  chiefly  subjective,  and  objective 
signs  of  structural  trouble  are  absent  or  not  prominent.  A  famil- 
iarity with  the  objective  signs  of  disease  of  the  various  joints  is  of 
course  necessary  in  making  the  diagnosis  of  functional  troubles, 
and  the  foregoing  chapters  have  dealt  with  those  objective  signs. 

Certain  symptoms  often  associated  with  functional  disorders  are 
ovarian  tenderness  and  pain,  baso-occipital  headache,  a  feeling  of 
suffocation  as  if  a  lump  were  lodged  in  the  throat,  and  symptoms 
of  this  class. 

The  association  of  uterine  disorders  is  common  and  also  another 
frequent  accompaniment  is  found  in  the  presence  of  errors  of  re- 
fraction in  the  eyes. 

The  correction  of  all  sources  of  peripheral  irritation  is  of  course 
a  matter  of  much  importance. 

Spine. 

In  functional  affections  of  the  spine,  pain  and  tenderness  are  fre- 
quently found  at  the  base  of  the  neck,  between  the  shoulders,  in 
the  lower  dorsal  region,  or  at  the  end  of  the  spine.  Spinal  irrita- 
tion is  one  of  the  terms  applied  to  this  condition.  This  pain  is 
usually  subacute,  it  is  aggravated  by  fatigue,  and  it  may  be  accom- 
panied by  much  hypera;sthesia,  which  is  usually  localized  in  a  com- 
paratively small  area,  where  there  is  a  complaint  of  a  burning  sen- 


FUNCTIONAL  AFFF.CT/ONS  ()/■'  7  J//''.  SPINl'l  AND  f./M/lS.     765 

sation,  while  no  curvature  or  projection  can  be  seen  on  inspection 
of  the  back.  In  the  extreme  cases,  patients  are  unable  to  bear 
any  weight  upon  the  spine  in  sitting  or  standing,  and  they  present 
the  symptoms  that  suggest  a  liyper^esthesia  of  the  ligaments  or  of 
the  fascia  of  the  back  muscles.  Ordinarily  the  patients  are  able  to 
go  about  freely,  but  suffer  great  pain,  especially  when  their  atten- 
tion is  turned  to  the  subject  of  themselves.  In  a  few  instances  of 
the  severest  sort  the  back  is  held  stiffly,  and  any  conscious  attempt 
at  bending  is  avoided  by  the  patient,  but  unconsciously  when  the 
patient's  attention  is  directed  in  another  way,  the  back  will  be  seen 
to  move  with  comparative  freedom. 

An  error  in  diagnosis  between  this  condition  and  lateral  curva- 
ture is  unnecessary  if  it  be  borne  in  mind  that  in  lateral  curvature 
in  the  early  stages  and  in  all  stages  except  that  of  extreme  deform- 
ity there  are  no  symptoms  of  pain  or  objective  symptoms  as  a  rule; 
the  only  complaint  being  the  prominence  of  the  shoulder  or  hip. 
In  functional  affections  of  the  spine  there  may  be  extreme  pain  and 
tenderness,  and  there  usually  is  some  pain  or  tenderness,  and  any 
lateral  deviation  of  the  spine  is  slight  and  incidental. 

A  much  more  difificult  diagnosis  is  between  functional  affection 
of  the  spine  and  Pott's  disease  before  the  presence  of  deformity.  . 

A  gait  which  is  very  similar  to  that  of  Pott's  disease  may  be 
present  and  also  rigidity  of  the  back  in  rising  or  stooping.  As  in 
that  affection  continued  standing  and  walking  may  cause  pain,  the 
patient  is  very  sensitive  to  any  jar  and  is  relieved  from  discomfort 
in  the  recumbent  position. 

A  careful  examination  of  the  patient  usuall}'  shows  that  the 
symptoms  of  stiffness  are  more  from  an  apprehension  of  possible 
pain  of  movement  than  the  unconscious  muscular  spasm  seen  in 
the  acuter  stages  of  early  Pott's  disease.  Pain  on  movement,  more- 
over, is  usually  much  greater  than  is  seen  in  early  Pott's  disease. 
Functional  affection  of  the  spine  is  more  common  in  adults  or  ado- 
lescents.    Pott's  disease  less  so. 

In  addition  to  this  it  should  be  remembered  that  in  Pott's  disease, 
in  the  early  stage  where  deformity  is  not  marked,  there  is  never 
any  tenderness  on  pressure  on  the  spinous  processes.  In  func- 
tional disease  of  the  spine  that  is  the  most  common  of  symptoms. 

Hip. 

The  symptoms  which  may  present  themselves  under  these  con- 
ditions at  the  hip-joint  may  resemble  hip  disease  in  many  particu- 
lars. There  is  often  complaint  of  a  severe  pain  in  the  limb,  and 
any  attempt  .to   move  the  hip   elicits   expression   of  pain.     There 


766  ORTHOPEDIC  SURGERY. 

may  be  an  absence  of  atrophy,  and  the  pain  is  more  Hkely  to  be 
locaHzed  at  the  hip  than  at  the  knee,  which  is  the  reverse  of  what 
happens  in  true  hip  disease.  Unconscious  movements  at  the  hip- 
joint  may  be  made  more  freely  than  in  the  painful  stages  of  hip 
disease.  In  some  instances,  marked  fixation  at  the  hip-joint  may 
constantly  be  present,  but  usually  the  stiffness  in  examination  of 
the  hip  is  great,  but  unconscious  movements  at  the  hip  as  in 
stooping  are  freer.  The  stiffness  is  more  the  stiffness  of  apprehen- 
sion than  the  limited  motion  in  early  disease  of  the  joint.  The 
affection  is  rare  in  children,  but  the  writers  can  mention  cases  in 
girls  of  eight  and  ten  years. 

The  deformity  may  be  marked  and  persistent,  recurring  quickly 
after  reduction,  but  frequently  the  normal  position  is  retained  by 
very  slight  means,  by  a  force  far  too  little  in  amount  to  produce  of 
itself  any  actual  benefit. 

Creaking  of  the  joint  may  be  present  in  both  hip  and  knee  in 
functional  affections.  Uncommon  at  the  hip,  it  is  a  frequent  symp- 
tom of  functional  knee-joint  disease.  This  symptom  is  described 
in  many  books  as  one  to  be  sought  for  in  destructive  joint  disease; 
it  may  be  said  again  that  it  is  not  a  common  sign  in  joint  disease. 
When  destructive  changes  in  the  joint  have  progressed  so  far  as 
to  destroy  the  cartilage  covering  the  ends  of  the  bones,  the  joint 
disease  will  have  assumed  so  acute  a  type  that  muscular  spasm  to 
a  marked  degree  will  be  present  and  prevent  any  motion  between 
the  eroded  surfaces.  This  will  naturally  prevent  the  perception 
of  any  grating  without  the  use  of  an  anesthetic,  a  proceeding 
which  is  wholly  unnecessary  and  will  only  allow  a  grating  to  be 
felt  in  the  more  advanced  cases  where  the  diagnosis  must  be 
already  clear. 

Knee. 

Functional  disease  of  the  knee-joints  often  simulates  either 
chronic  synovitis  or  ostitis.  Pain  and  tenderness  may  be  present, 
creaking  is  noted  as  an  occasional  symptom  in  functional  affec- 
tions, and  at  times  there  seems  to  be  present  an  increase  of  surface 
temperature,  which  is  apparently  due  to  superficial  hyperaeraia.  It 
is  not  constantly  present  in  the  same  case,  and  it  varies  in  a  way 
altogether  unlike  the  behavior  of  the  heat  of  chronic  inflammation. 
More  commonly  the  surface  temperature  of  the  affected  side  is  re- 
duced. The  knee  may  be  flexed,  but  during  sleep  that  position 
may  be  involuntarily  abandoned  or  the  leg  can  be  easily  straight- 
ened, offering  but  little  resistance.  Contraction  of  the  knee  is 
often  absent.  . 


FUNCTIONAL  AFFKCT/ONS  ()/••  Till':  S/'/N/C  AND  fJM/lS.     'jf^-j 

A  moderate  degree  of  niusculai"  atrophy  is  jH'eseiit,  and  in  some 
cases  of  prolonged  disease  of  the  joint  peri-articular  adhesions 
may  be  formed  and  contractions  from  adapted  slu^rtening  of  the 
muscles. 

In  rare  instances  some  swelling  of  the  periarticular  tissues 
around  the  knee  is  observed  in  this  class  of  cases.  The  swelling  is 
transitory  and  does  not  involve  the  joint  proj;er. 

An  KM',. 

A  condition  of  the  ankle  similar  to  what  has  been  described  is 
not  infrequent.  It  is  most  commonly  met  as  a  result  of  sprains 
which  have  been  treated  for  too  long  a  time  by  rest  and  fixation. 
A  condition  of  muscular  weakness,  enfeebled  circulation,  and  appre- 
hension at  slight  pain  ensues,  and  no  attempt  at  the  proper  means 
of  securing  recovery  is  made,  for  the  reason  that  the  first  attempt 
to  use  the  disabled  joint  is  painful  and  pain  is  regarded  as  a  symp- 
tom indicative  of  inflammation. 

In  functional  disease  of  the  ankle  an  attitude  similar  to  talipes 
varus  or  of  flat-foot  may  be  seen.  In  one  case  of  talipes  \'arus 
seen  by  the  writers  there  was  an  exaggerated  limp,  and  when  the 
patient's  attention  was  engaged  the  foot  could  be  replaced  and 
even  over-corrected,  yet  at  other  times  it  presented  a  firm  resistant 
contraction.  The  distorted  attitude  in  both  the  knee  and  the  ankle 
may  be  so  constantly  assumed  as  to  cause  a  contraction  of  the  ham 
strings  or  tendo  Achillis. 

The  functional  affections  of  the  other  joints  present  no  points 
worthy  of  especial  mention. 

Diagnosis. 

So  much  has  been  said  about  the  characteristics  of  these  affec- 
tions in  speaking  of  the  various  joints  that  there  is  scarce!}-  need 
of  mention  here.  It  may,  however,  be  said  that  the  symptoms  are 
nften  those  of  organic  joint  disease,  but  that  the  groups  of  objec- 
tive physical  signs  are  deficient.  The  objective  signs  vary  and  are 
not  as  severe  as  the  symptoms  would  lead  one  to  expect.  Pain  is 
the  prominent  feature  and  muscular  rigidity  and  similar  symptoms 
are  of  varying  severity,  according  to  the  concentration  of  the  pa- 
tient's attention.  The  presence  of  superficial  hyperjesthesia  and  an 
emotional  temperament  are  facts  which  should  excite  attention. 

In  examining  patients  where  a  functional  affection  is  suspected, 
much  information  can  be  gained  by  watching  the  movements  of 
the  patient  in  getting  out  of  bed,  moving  in  bed,  etc.     The  limbs 


768  ORTHOPEDIC  SURGERY. 

or  back  should  be  bared,  and  the  unaided  movements  watched. 
Those  suffering  from  organic  disease  of  the  hip  or  spine  show  a 
constant  stiffness  or  attempt  to  guard  or  protect  the  affected  Hmb, 
which  is  not  displayed  to  as  marked  a  degree  in  purely  functional 
affections. 

Prognosis. 

If  left  to  itself,  a  true  functional  affection  of  the  spine  or  joints 
may  improve  gradually  without  special  treatment,  or  it  may  re- 
main unchanged  until  the  joint  becomes  really  injured  by  the 
continued  inaction.  In  some  cases  a  sudden  and  strong  mental 
impression  may  prove  stronger  than  the  idea  of  local  disease  and 
a  cure  is  effected.  It  is  this  that  the  surgeon  strives  to  accomplish 
in  certain  cases,  it  is  this  that  may  be  brought  about  by  faith  cure 
or  charlatanry,  and  rational  treatment  of  a  similar  sort  can  like- 
wise win  excellent  results  if  properly  carried  out. 

The  age  of  the  patient  and  the  duration  of  the  affection  are  im- 
portant in  determining  the  outlook.  The  older  the  patient  and  the 
longer  the  course  of  the  disease  the  less  favorable  is  the  prognosis. 

The  existence  of  some  peripheral  source  of  irritation,  such  as  is 
so  often  found  in  an  error  of  refraction  in  the  cornea  or  in  a  mis- 
placed uterus,  renders  it  likely  that  the  general  condition  will  be 
helped  by  a  removal  of  the  irritating  cause  and  renders  the  imme- 
diate prognosis  perhaps  more  favorable. 

Treatment. 

In  few  disorders  is  a  routine  treatment  of  less  use  than  in  func- 
tional affections  of  the  joints  or  spine.  In  severe  cases  the  treat- 
ment begins  with  a  contest  of  intelligence  between  the  patient  and 
physician,  and  treatment  is  futile  unless  the  superiority  of  the 
physician  is  evident  to  both  the  physician  himself  and  the  patient. 
Especially  important,  from  the  outset  to  the  end  of  the  treatment, 
is  an  established  diagnosis,  on  which  the  surgeon  can  rely.  To 
attempt  to  follow  out  a  treatment  which  shall  be  suitable  to  either 
functional  or  organic  disease  is  simply  fatal  to  a  successful  issue. 
Temporizing  on  the  part  of  the  physician  at  once  makes  successful 
treatment  almost  impossible.  A  definite  plan  of  treatment  must 
be  formulated  and  adhered  to. 

The  disorder  usually  manifests  itself  as  a  disability  of  a  limb, 
the  object  of  treatment  being  to  overcome  the  disability.  Various 
methods  will  be  needed  to  effect  this. 

It  is  first  necessary  that  the  patient  be  brought  into  as  nearly 
a  normal  general   condition   as   is   possible.     The   improvement  of 


l''UNCTIONAL  AI''J''h:C'rn)NS  ()/'■  '////■:  S/'INI'l  AND  IJMHS.     yOj 

the  local  condition  is  tlicn  to  be  considered  and  estimated,  and 
finally  the  patient  is  to  be  trained  to  regain  tlie  use  (A  the  disabled 
limb. 

A  full  description  of  the  measures  necessary  for  tlie  j^ropcr  treat- 
ment of  neurastlienic  patients  does  not  fall  within  the  scope  of  this 
work,  but  this  class  of  cases  cannot  be  successfully  treated  unless 
due  attention  is  i^iven  to  re<^ulatin^r  and  im[>rovin^  diet,  general 
condition,  and  correctini;'  sleeplessness. 

For  the  treatment  of  the  local  condition,  the  physician  has  to 
decide  between  the  necessity  of  correcting  any  existing  distortion 
or  local  improper  condition  of  circulation  or  muscular  weakness  of 
the  limb  or  back,  and  the  danger  of  increasing  the  expectant  at- 
tention of  the  patient  by  too  great  attention  to  the  local  condition. 
It  is  for  this  reason  that  counter-irritation  and  the  cautery  are  to 
be  avoided. 

It  is  essential  that  the  local  condition  should  not  be  made  light 
of  by  the  surgeon,  and  the  reality  of  the  symptoms  must  be 
accepted  and  the  disability  recognized. 

A  probable  hypothesis  explaining  the  condition  must  be  assumed, 
and  treatment  based  upon  this  should  be  carefully  and  consistently 
carried  out.  Any  statement  that  the  affection  is  a  trivial  nervous 
disorder  or  that  it  can  be  overcome  by  exercise  of  the  will  is  in 
most  cases  a  fatal  error. 

An  important  part  of  local  treatment  is  the  improvement  of  the 
circulation  in  the  part  affected,  and  strengthening  the  surrounding 
muscles.  This  can  be  done  by  massage,  electricity,  and  gymnastics, 
and  the  functions  of  the  part  gradually  gained  by  slight  passive 
motion. 

Another  aspect  of  the  case  lies  in  the  moral  management  of  the 
patient,  a  matter  which  will  be  successful  or  not  generall}'  in  pro- 
portion to  the  tact  and  judgment  of  the  practitioner.  Some 
patients  can  be  commanded  to  walk  and  will  do  so  and  a  cure  is 
accomplished,  while  in  the  majority  of  cases  to  attempt  a  measure 
of  this  sort  would  lead  to  a  permanent  loss  of  influence  on  account 
of  the  failure  of  the  surgeon  to  have  his  directions  carried  out. 
Elaboration  of  treatment  is  desirable  in  many  cases  and  a  rigid 
adherence  to  a  careful  and  continuous  routine  of  exercises,  feeding, 
and  medication  must  be  insisted  upon.  In  no  class  of  diseases  do 
proper  placebos  work  more  good. 

In  general  the  beneficial  efTect  of  the  local  measures  adopted 
must  be  insisted  on,  and  by  a  graduated  amount  of  enforced  exer- 
cise progressively  increased,  the  patient  may  be  surprised  into 
finding  herself  daily  doing  more  w-ithout  feeling  more  pain.  Some- 
times it  may  be  only  practicable  to  make  the  patient  take  two 
49 


770 


Ok  THOPEDIC  S  URGER  V. 


steps  a  day,  but  the  advance  to  three  and  four  steps  is  an  impor- 
tant gain.  It  may  be  repeated  that  without  a  certainty  on  the 
physician's  part  that  he  is  dealing  with  a  functional  affection  and 
without  a  rigid  adherence  to  his  formulated  plan  of  treatment, 
success  is  not  often  to  be  obtained. 

Great  benefit  can  be  obtained  by  graduated  exercises  in  this 
class  of  cases,  according  to  the  methods  of  the  so-called  Swedish 
movement  conducted  by  proficients  in  this  method. 

Another  useful  way  of  accomplishing  this  result  is  by  means  of 
mechanical  passive  and  active  exercises  according  to  the  method 
introduced  by  Zander.     This  consists  of  appliances  in  which  the 


a) 


Fig.  786. — Spring  Steel  Appliance  for  Muscular 
Weakness  of  Spine. 


Fig.  787, — Corset  with  Steel  Supports  for  Muscular 
Weakness  of  Spine. 


amount  of  resistance  or  assistance  to  motions  of  the  limbs  can  be 
regulated  by  means  of  weights  sliding  upon  rods  moving  upon  a 
pivot,  these  rods  being  attached  to  the  limbs  to  be  exercised. 

The  distance  of  these  weights  from  the  centre  of  motion  will 
increase  the  resistance  to  be  encountered  or  will  aid  the  movement 
of  the  limb  according  to  the  direction  in  which  they  are  employed. 
These  appliances  are  costly  and  can  only  be  furnished  in  institu- 
tions or  especially  made  for  individual  cases  at  much  expense.  In 
place  of  these,  under  proper  direction,  the  ordinary  gymnastic  ap- 
pliances can  be  made  to  be  of  service. 

Appliances  as  a  rule  should  be  avoided — but  in  some  cases  they 
are  temporarily  needed — to  enable  the  patient  to  go  about  more 
freely  in   cases  with  marked  muscular  weakness.     They  should  be 


FUNCTIONAL  AFFECTIONS  OF  Tlf  E  SPI Nl'l  AND  IJM/iS. 


771 


discarded  as  soon  as  is  practicable;  in  the  scvcTcr  forms  crutches 
will  be  an  aid  when  walking  is  first  attempted,  and  plaster  jackets 
have  been  occasionally  used  with  advantage.  They  should,  how- 
ever, only  be  employed  for  a  short  time,  as  they  increase  the 
muscular  weakness.  The  same  is  true,  but  to  a  less  degree,  of  the 
lighter  forms  of  appliances — spring  corsets  and  light  appliances 
as  illustrated  in  the  accompanying  cuts. 

The    trea'tment    for   spinal    irritation    can    be    briefly  stated    as 
follows: 


Fig.  788. — Spring  Steel  Appliance  Adjusted. 


Fig.  789. — Appliance  Adjusted. 


1.  Enforced  recumbency,  temporarily  galvanism,  massage,  tonics, 
for  the  severest  cases  with  marked  evidence  of  nervous  exhaustion. 

2.  Graduated  mechanical  exercises  for  the  lighter  cases,  begin- 
ning with  exercises  so  slight  as  to  be  done  with  little  fatigue  and 
increasing  daily  until  the  muscles  become  capable  of  performing 
ordinary  work  Avithout  fatigue. 

3.  The  temporary  use  of  mechanical  supports,  in  such  cases  as 
cannot  undergo  gymnastic  treatment.  The  gymnastic  exercises  of 
benefit  are  those  described  under  the  head  of  affection  of  the  spine. 

4.  The  general  encouragement  of  the  patient  to  take  continually 
more  exercise  and  approach  a  more  normal  standard  of  life. 

In  functional  affections  of  the  hip,  knee,  and  ankle  it  is  some- 


772 


ORTHOPEDIC  SURGERY. 


times  necessary  to  employ  crutches  in  order  to  give  locomotion 
and  exercise.  "  Crutches  should  be  used  sparingly,  and  only  tem- 
porarily, inasmuch  as  there  is  danger  of  the  patient  becoming 
habituated  to  them. 

Where  contractions  and  malposition  of  the  limbs  are  present, 
these  should  be  corrected  either  by  operation  or  by  mechanical 
means.  Operative  measures  are  usually  simple,  as  under  an  anaes- 
thetic the  limb  can  be  pulled  readily  into  normal  position,  while  in 
severe  cases  tenotomy  of  the  resisting  muscles  is  needed.  Appli- 
ances will  be  required  to  retain  the  limb  in  the  corrected  position. 
Tin  or  light  wire  splints  strapped  upon  the  limb  are  preferable  to 
fiixed  bandages,  as  they  confine  the  limb  less. 

Contraction  of.  the  hip  as  well  as  of  the  knee  can  ordinarily  be 
prevented  from  occurring  by  posterior  splints,  as  the  psoas  contrac- 
tion in  a  functional  affection  of  the  hip  usually  in  time  yields  to 
the  weight  of  the  extended  limb  if  the  patient  is  upright  and  the 
knee  prevented  from  bending  by  a  ham  splint. 

Light  cases  of  functional  affection  of  the  hip  will  be  best  treated 
at  first  by  the  use  of  crutches  and  the  elevated  shoe  to  the  well 
foot,  aided  by  gymnastic  exercises  for  the  limb  of  such  a  character 
as  the  patient  can  endure.  The  elevated  shoe  should  be  lowered 
and  removed  gradually,  and  in  the  same  way  crutches  should  be 
shortened  and  replaced  by  a  cane,  and  finally  all  support  discarded 
by  gradual  steps.  The  use  of  a  hip  splint  will  not  be  found  advan- 
tageous on  account  of  its  weight.  Traction  by  weight  and  pulley 
is  rarely  needed,  but  is  sometimes  advisable.  Treatment  of  light 
cases  of  disease  of  the  knee  and  ankle  may  often  require  the  tem- 
porary use  of  crutches  and  possibly  fixation  appliances  for  a  while. 

Much  judgment  is  required  to  determine  what  cases  of  functional 
affection  of  the  hip,  knee,  and  ankle  joints  are  to  be  treated  by  rest, 
by  protection  of  the  limb,  or  by  use. 

Rest  in  bed  is  to  be  avoided  unless  the  patient  is  in  a  marked 
neurasthenic  condition  needing  quiet.  In  some  instances  confine- 
ment to  bed  is  unavoidable  during  the  correction  of  deformity. 

Crutches  form  the  readiest  temporary  method  of  protection. 
They  should  be  used  in  all  cases  where  the  patients  are  unable  to 
walk  on  account  of  disability  of  the  limb  or  where  they  limp  badly. 

Gymnastic  exercises  and  rubbing  can  be  employed,  but  in  the 
extremely  hyperaesthetic  stage,  local  applications  should  be  avoided 
and  the  use  of  the  cautery  is  not  necessary  and  often  injurious.  In 
functional  affection  of  the  limbs  the  strength  of  the  muscles  con- 
trolling the  diseased  joint  should  be  increased  by  graduated  exer- 
cise, until  the  patient  is  surprised  into  an  unconscious  use  of  a 
previously  disabled  limb.     If   removal  of  crutches  or  supports  is 


FUNCTIONAL  AJ'J'JiC'J'JONS  ()/■    'rilh.SI'JNEANJ)  J.IMJIS. 


773 


attempted  before  the  strength  of  llic  limb  is  certain,  a  mistake 
is  made  and  crutches  will  be  resumed  by  the  ]jalient.  If  the 
strength  of  the  part  has  been  regained,  use  is  possible  if  tiie  atten- 
tion of  the  patient  expectant  of  suffering  can  be  diverted  until  the 
painless  use  of  the  part  has  been  demonstrated. 

Whatever  the  methods  of  treatment  to  be  instituted,  it  is  abso- 
lutely essential  that  the  physician  should  have  complete  control  of 
the  management  of  the  case  without  interference  of  friends  or 
relations.  Sometimes  it  is  therefore  necessary  to  take  the  patient 
away  from  home  for  the  time  being.  In  many  cases  the  home 
influence  is  a  most  important  factor  in  inducing  and  keeping  up 
this  condition,  so  that  a  removal  from  these  influences  is  essential. 

In  cases  where  functional  symptoms  are  superadded  to  an  or- 
ganic lesion,  much  skill  and  judgment  are  required  in  treatment. 

In  all  these  varieties  of  functional  affections,  the  principle  of 
treatment  is  the  same — temporarily  to  protect  the  affected  part 
from  strain  and  painful  use,  to  improve  the  circulation  and  increase 
the  muscular  strength,  and  as  the  condition  improves  to  train  the 
patient  to  the  gradual  resumption  of  the  normal  use  of  the  spine 
or  limb. 


GENERAL    INDEX. 


Abdominal  pain  in  Pott's  disease,  i8 
Abduction,  calculation  of,  283 
Abscess  in  hip  disease,  272,  298,  323 

in  tumor  albus,  372,  387 

peri-articular,  229 
Absorption  of  abscesses  in  Pott's  disease,  33 
Acquired  club-foot,  507 
Acromio-clavicular  joint,  diseases  of,  449 
Acute  arthritis  in  infants,  24S 

arthritis  in  infants,  hip-joint,  364 

infectious  diseases  in   relation  to   joint 
disease,  244 

infectious  osteo-myelitis,  229 
Adams'  club-foot  appliance,  481 

operation  for  Dupuytren's  contraction, 
722 

operation  for  hip  disease,  331 
Adduction  and  abduction  in  hip  disease,  269 

calculation  of,  283 
Age  in  tuberculous  joint  disease,  237 
Albert's  operation  in  infantile  paralysis,  576 
Amputation  in  hip  disease,  355 

in  knee-joint  disease,  396 
Anatomy  of  club-foot,  450 
Angular  ankylosis  in  tumor  ilbus,  384 

curvatures  of  spine,  see  Pott's  disease 
Ankle,  functional  affection  of,  767 

hysterical  affection  of,  767 
Ankles,  weakness  of,  733 
Ankle-joint,  arthritis  deformans,  427 

caries,  418 

excision  of,  423 

fungous  synovitis,  418 

serous  synovitis,  41 8 

teno-synovitis,  421 
Ankylophobia  in  joint  disease,  307 
Ankylosis,  250 

of  knee,  384 
Apparent  shortening,  2S2 
Appliances,  Pott's  disease,  61 
Arthrectomy  of  elbow,  440 

in  knee-joint  disease,  395 
Arthritis  deformans,  225 

deformans  of  ankle,  427 

deformans  of  hip,  361 

deformans  of  knee,  403 

deformans  of  shoulder,  431 
Articular  ostitis,  pathology  of,  214 


Aspiration  of  abscesses,  326 
Astragaloid  osteotomy,  494 
Astragalus  in  club-foot,  451 
Ataxic  paraplegia,  609 
Atrophy  in  hip  disease,  2G5,  286 

in  tumor  albus,  369 

unilateral,  712 
Attitude  in  hip  disease,  281 

in  Pott's  disease,  12 

in  psoas  contraction,  16 

in  sleep,  154 

of  rest,  641 

Bacilli  in  joint  disease,  220 

Bandy  legs,  671 

Barwell's  apparatus  for  lateral  curvature,  168 

Bed  frame  in  hip  disease,  319 

Beely's  appliance  for  club-foot,  466 

P>ifurcation  of  hand,  531 

Billroth's  correction  splint  in  tumor  ai.  us, 

381 
Bonnet's  experiments  on   joint    distent  on, 

268 
Bow-legs,  639,  671 

anterior  curves,  686 

causation,  672 

diagnosis,  677 

elasticity  of  bones,  676 

expectant  treatment,  678 

mechanical  treatment,  681 

occurrence,  671 

operative  treatment,  683 

osteoclasis.  6S4 

osteostomy,  687 

osteotomy,  687 

prognosis,  678 

results  of  operative  treatment,  688 

spontaneous  recovery,  680 

symptoms,  675 

varieties  of  curves,  675 
Brackett's  perineal  band.  312 
Brisement  force  in  hip  disease,  329 

in  tumor  albus.  385 
Brown's  case  of  congenital  dislocation   of 
hip,  520 

appliance  for  torticollis,  703 
Bunion,  754 
Burrell's  splint  for  infantile  paralysis,   571 


Tj6 


GENERAL   INDEX. 


Bursitis,  230 
of  heel,  428 
of  knee,  411 

Cabot's  posterior  wire  splint  for  hip  dis- 
ease, 305" 
Carcinoma  of  the  spine,  igg 
Caries  of  joints,  214 
of  ankle  joint,  418 

of  spine,  see  Pott's  disease 
Cartilage,  diseases  of,  209 

of  knee,  primary  disease,  416 
Causes  of  death  in  hip  disease,  295 
Cerebral  paralysis  in  children,  578 

paralysis,  diagnosis,  591 

paralysis,  differential  diagnosis,  592 

paralysis,  etiology,  586 

paralysis,  mechanical  appliance,  598 

paralysis,  mental  training,  596 

paralysis,  operative  treatment,  596 

paralysis,  pathology,  589 

paralysis,  prognosis,  593 

paralysis,  summary  of  treatment,  599 

paralysis,  tenotomy,  596 

paralysis,  treatment,  594 

paralysis,  trephining,  599 

tumor,   592 
Chair  for  lateral  curvature,  152 
Charcot's  disease  of  knee-joint,  414 

disease  of  shoulder,  432 
Chinese  lady's  foot,  752 
Choice  of  treatment  in  lateral  curvature,  182 
Chondritis,  209 
Chronic  synov-itis,  360 

purulent  synovitis  of  knee,  366 
Club-foot,  450 

anatomy  of,  450 

astragaloid  osteotomy,  494 

astragalus  in,  451 

causation  of  453 

diagnosis,  457 

division  of  ligaments,  476 

elastic  traction,  468 

forcible  correction,  483 

imperfect  results,  502 

ligaments  in,  453 

mechanical  appliances,  477 

mechanical  correction,  463 

open  incision,  482 

operative  treatment,  471,  482 

prognosis,  459 

relapses,  501 

retentive  appliances,  497 

summary  of  treatment,  503 

symptoms,  456 

Taylor's  shoe,  467 

tenotomy,  473 

treatment,  400 

treatment  of  muscles,  503 

walking  apphances,  497 
Club-hand,  527 

Compression  in  joint  disease,  253 
Congenital  deformities  of  fingers  and  toes, 

527 
dislocations,  509 
dislocations,  etiology,  510 


Congenital  dislocations,  pathology,  512 
dislocation  of  hip,  290,  510 
dislocation  of  hip,  diagnosis,  514 
dislocation  of  hip,  prognosis,  517 
dislocation  of  hip,  symptoms,  514 
dislocation  of  hip,  operative  treatment, 

521 
dislocation  of  hip,  treatment,  519 

Conservative  treatment  of   hip  disease,  291 

Contractions  in  hemiplegia,  581 

Contraction  of  iingers  and  toes,  congenital, 
536 

Convalescent  splint  in  hip  disease,  321 

Corsets  in  lateral  curvature,  167 

Course  of  chronic  joint  disease,   231 

Craniotabes,  624 

Curvature  of  spine,  antero-posterior,  i 
of  spine,  fixed  curves,  122 
of  spine,  flexible  curves,  122 
of  spine,  lateral,  103 
of  spine  in  lateral  curvature,  109 
of  spine,  physiological,  122,  184 
of  spine,  structural  curves,  122 

Cysts  of  knee-joint,  413 

Davis'  hip  splint,  310 

Deficiencies  of  fingers  and  toes,  532 

Deformities  in  infantile  paralysis,  545 

of  fingers  and  toes,  congenital,  527 

of  foot  in  infantile  paralysis,  574 

of  toes,  753 
Deformity  in  lateral  curvature,  108 

in  Pott's  disease,  25 

of  hip  in  infantile  paralysis,  572 
Didot's  operation  for  webbed  fingers,  534 
Diseases  of  synovial  membrane,  202 
Dislocations  from  infantile  paralysis,  552 
Displacement  of  viscera  in  lateral  curvature, 

140 
Distortion  after  hip  disease,  299 

of  thorax,  200 
Distribution  of  chronic  joint  disease,  248 
Division  of  ligaments  in  club-foot,  476 
Double  hemiplegia,  583 

hip  disease,  276,  337 
Dry  synovitis,  206 
Dupuytren's  contraction  of  fingers,  715 

Adams'  operation,  722 

after-treatment,  726 

diagnosis,  721 

etiology,  717 

mechanical  treatment,  726 

medical  treatment,  726 

open  incision,  724 

pathology,  715 

prognosis,  722 

symptoms,  720 

treatment,  722 
Duration  of  treatment  in  hip  disease,  297 

Elbow-joint,  diseases  of,  435 
Epilepsy  in  cerebral  paralysis,  5S0 
Epiphyseal  hypereemia,  290 
Essential  paralysis  of  children,  538 
Etiology  of  joint  disease,  231 
Excision  of  ankle-joint,  423 


GENERAL   INDEX. 


777 


Excision  of  elbow,  438 

of  hip,  338 

of  hip,  causes  of  death,  345 

of  hip,  indications  for,  351 

of  hip,  mortal ily,  343 

of  hip,  results,  344,  346,  349 

of  hip,  shortening',  351 

of  hip,  unsuccessful,  346 

of  joints  in  infantile  paralysis,  576 

of  knee,  387,  388 

of  shoulder-joint,  433 

of  tarsus,  490 

of  the  knee  for  angular  ankylosis,  394 

of  wrist,  442 
Exercises  in  lateral  curvature,  161 
Exostoses,  227 

Experiments  in  causation  of   lateral   curva- 
ture,   126 

Faulty  attitudes,  155 
Feet,  affections  of,  727 
Felt  jacket,  68 
Fingers,  contraction  of,  536 

deficiencies  of,  532 

Dupuytren's  contraction,  715 

hypertrophy  of,  532 

joints,  diseases  of.  448 

supernumerary,  529 

tumors  of,  536 

webbed,  533 
Fixation  frame  in  Pott's  disease,  56 

in. joint  disease,  253 

in  treatment  of  tumor  albus,  375 

splints  in  hip  disease,  301 
Flat-foot,  727 

appliances  for,  741 

congenital,  727 

diagnosis,  737 

etiology,  728 

inflammatory,  730 

operative  treatment,  742 

pain,  735 

pathological  anatomy,  730 

predisposing  causes,  731 

relation  to  knock-knee,  642 

symptoms  of,  734 

tenderness,  735 

I'homas  shoe,  741 

traumatic,  730 

treatment  of,  738 
Flexibility  of  spinal  column,  36 
Flexion,  calculation  of,  2S5 

in  tumor  albus,  379 
Foot  of  Chinese  lady,  752 

sole  of,  in  infants,  729 
Forcible  correction  of  club-foot,  483 

straightening  in  tumor  albus,  381 
Friedreich's  disease,  609 
Functional  affections,  761 

affections,  diagnosis.   767 

affections,  etiology,  762 

affections,  frequency,  762 

affections,  prognosis,  768 

affections,  symptoms  of,  763 

affections,  treatment,  768 
Fungous  joint  disease,  206 


Fungous  synovitis  of  knee,  366 

Gait  in  spastic  paralysis,  583 
Gant's  operation  in  hip  disease.  332 
Genu,  valgum,  639;  see  also  Knock-knee 

varum,  671 
Gout,  243 

Gouttiere  de  Bonnet,  305 
Growing  pains,  247 
Gummatous  ostitis,  224 
Gymnastics  in  lateral  curvature,  159 

H/iCMoiMiii.iA,  247 

Halm's  operation  for  knock-knee,  667 

Hallux  rigidus,  756 

valgus,  753 

valgus,  operative  treatment,  755 

valgus,  shoes  for,  755 

varus,  756 
Hammer  toe,  757 
Hand,  bifurcated,  531 
Heat  in  tumor  albus,  370 
'Height,  table  of,  149 
Hemiplegia  and  spastic  paralysis,  584,  590 

contractions,  581 

disorders  of  movement,  581 

in  children,  578 

mental  impairment,  5S0 

operation  for  deformity,  598 

symptoms,  579 

unilateral  sweating,  581 
Hemorrhagic  synovitis  of  hip,  365 
Hereditary  attaxia,  609 
Heredity  in  club-foot,  454 

in  tuberculous  joint  disease,  234 
Hip  disease,  255 

disease,  abscess,  272,  298,  323 

disease,  adduction  and  abduction,  269, 
283 

disease,  amputation,  355 

disease,  atrophy,  265,  286 

disease,  attitude,  281 

disease,  bed  frame,  319 

disease,  brisement  force,  329 

disease,  causes  of  death,  295 

disease,  clinical  history,  260 

disease,  complications,  323 

disease,  convalescent  splint,  321 

disease,  diagnosis,  277 

disease,  differential  diagnosis,  287 

disease,  duration  of  treatment,  297 

disease,  early  symptoms,  260 

disease,  excision,  33S 

disease,  fixation  and  traction,  315 

disease,  general  condition,  275 

disease,  ignipuncture,  354 

disease,  incision  of  joint,  354 

disease,  lameness.  262,  280 

disease,  malpositions  of  the  limb,  267^ 

327 
disease,  mortality,  295 
disease,  muscular  fixation.  265 
disease,  night-cries,  264,  326 
disease,  operative  treatment,  338 
disease,  osteoclasis,  330 
disease,  osteotomy,  330 


77^ 


GENERAL   INDEX. 


Hip  disease,  pain,  262,  2S7 
disease,  pathology,  255 
disease,  peri-articular  symptoms,  271 
disease,  prognosis,  299 
disease,  protection,  320 
disease,  relapses,  323 
disease,  shortening  of  limb,  274,  281, 

299.  337 
disease,  short  traction  splint,  318 
disease,  stiffness,  265,  278 
disease,  summary  of  treatment,  358 
disease,  temperature    276 
disease,  traction  by  weight  and  pulley, 

315 

disease,  treatment,  301 

disease,  trephining,  354 

joint,  acute  arthritis,  364 

joint,  arthritis  deformans,  361 

joint,  chronic  synovitis,  360 

joint,  congenital  dislocation,  510 

joint,  functional  affections  of,  765 

joint,  hemorrhagic  synovitis,  365 

joint,  loose  cartilage,  365 

joint,  malignant  disease,  365 

joint,  periostitis,  364 

joint,  syphilitic  disease,  364 
Housemaid's  knee,  411 
Hydrarthron,  204 
Hydrocephalus  in  rickets,  625 
Hydrops  articuli,  204 

articulorum  tuberculosus,  205 

of  knee,  399 
Hypersesthetic  spine,  45 
Hypertrophy  of  fingers  and  toes,  532 

unilateral,  712 
Hysterical  affections,  see  Functional  Affec- 
tions 

ankle,  767 

hip-joint,  290,  765 

knee,  766 

spine,  764 

Idiocy,  symptoms  of,  585 
Ignipuncture  in  hip  disease,  354 
Immobilization  in  hip  disease,  307 
Incision  of  joint  in  hip  disease,  354 
Incoordination  in  children,  578 

symptoms  of  585 
Infantile  paralysis.  538 

paralysis,  appliances  for,  566 
paralysis,  atrophy,  544 
paralysis,  deformities,  545 
paralysis,  deformities  of  leg,  547 
paralysis,     deformities    of    foot,    550, 

574 
paralysis,  deformity  of  arm,  551 
paralysis,  deformity  of  hip,  572 
paralysis,  diagnosis,  554 
paralysis,  differential  diagnosis,  555 
paralysis,  dislocations,   552 
paralysis,  distribution,  544 
paralysis,  electrical  reaction  in,  554 
paralysis,  electricity  in,  561 
paralysis,  etiology,  538 
paralysis,  excision  of  joints,  576 
paralysis,  flexion  of  knee,  573 


Infantile  paralysis,  indications  for  mechani- 
cal treatment,  564 

paralysis,  lateral  curvature,  552 

paralysis,  mechanical  treatment,  564 

paralysis,  massage  in,  562 

paralysis  of  thigh  muscles,  567 

paralysis,  operative  treatment,  574 

paralysis,  osteoclasis,  577 

paralysis,  osteotomy,  576 

paralysis,  pathology,  540 

paralysis,  prognosis,  558 

paralysis,  sequelce,  545 

paralysis,  symptoms,  542 

paralysis,  tendon  refiex,  544 

paralysis,  tenotomy,  574 

paralysis,  traumatic  cases,  541 

paralysis,  treatment,  559 

paralysis,  valgus  shoe,  566 

spinal  paralysis,  538 
Intermittent  hydrops  articuli,  403 

torticollis,  698,  709 
Internal  derangemant  of  knee-joint,  408 
Irrigation  in  chronic  synovitis  of  knee,  402 

Joint  disease,  bacilli  in,  220 

disease,  course  of,  231 

disease,  etiology,  231 

disease,  pathology  of,  202 
Joints,  functional  affections  of,  763 

hysterical  affections  of,  761 

tumors  of,  227 
Judson's  experiment   in   lateral  curvature, 

136 
Jury-mast,  60 

Knee-joint,  arthritis  deformans,  403 

bursitis,  411 

Charcot's  disease,  414 

chronic  purulent  synovitis,  366 

chronic  synovitis,  398 

cysts  of,  413 

disease  of  cartilage,  416 

diseases  of,  398 

functional  affection  of,  766 

fungous  synovitis,  366 

hysterical  affection  of,  766 

internal  derangement,  408 

loose  bodies,  406 

loose  cartilage,  406 

scrofulous  disease,  366 

strumous  arthritis,  366 
.  synovitis,  treatment,  401 

tubercular  disease,  366 

tumor  albus,  366 
Knock-knee,  639 

bony  deformity,  642 

Delore's  method,  663 

diagnosis,  649 

excision  in,  671 

expectant  treatment,  653 

forcible  straightening,  b63 

from  tumor  albus,  651 

gait  in,  644 

Hahn's  operation,  667 

Macew^en's  operation,  667 

measurement  of  deformity,  649 


GENERA  L   INI)  EX. 


79 


Knock-knee,  mechanical  production,  640 

mechanical  treatment,  656 

occurrence  and  etiolojjy,  63?) 

Ojjston's  operation,  668 

operative  treatment,  662 

osteoclasis,  670 

osteotomy,  664 

paralytic  form,  651    , 

proj^nosis,  652 

Reeve's  operation,  669 

relation  to  flat-foot,  642- 

results  of  operative  treatment,  688 

secondary  deformities,  648 

symptoms,  643 

tenotomy,  663 

traumatic  form,  651 
Kolbe's  club-foot  appliance,  581 
Kyphosis,  186;  see  Pott's  disease 

treatment,  188 

Lameness  in  hip  disease,  262,  280 

in  tumor  albus,  370 
Laminectomy,  97 
Laryngismus  stridulus,  629 
Lateral  curvature,  103 

curvature,  causation  of,  123 

curvature,  cervical  curve,  m 

curvature,  chair,  152 

curvature,  choice  of  treatment,  182 

curvature,  corsets,  167 

curvature,   diagnosis,  141 

curvature,  displacement  of  viscera,  140 

curvature,  distortion  in,  108 

curvature,  distortion  of  pelvis,  139 

curvature,  dorsal  curve,  ill 

curvature,  double  curve,  114 

curvature,  etiology,  124 

curvature,  exercises,  161 

curvature,  experiments  as  to  causation, 
126 

curvature,  faulty  attitudes,  155 

curvature,  fixed  curves,  122 

curvature,  flexible  curves,  122 

curvature,  frequency,  104 

curvature,  gymnastics,  159 

curvature,  infantile  paralysis,  552 

curvature,  limp,  115 

curvature,  lumbar  curve,  113 

curvature,  mechanical  appliance,  173 

curvature,  mechanical  treatment,  165 

curvature,  methodical  correction,  177 

curvature,  methods  of  recording,  146 

curvature,  normal   height   and   weight, 
149 

curvature,  oblique  seat,  166 

curvature  of  spine,  109 

curvature,  operative  measures,  180 

curvature,  paralytic,  120 

curvature,  pathology,  134 

curvature,  prevention  of,  150 

curvature,  prognosis,  147 

curvature,  reclining  couches,  181 

curvature,  record  in,  146 

curvature,  rhachitic,  118 

curvature,  school  seats,  153 

curvature,  sex  in,  105 


l.aicrai  curvature,  situation,  115 

curvature,  stages  of,  io6 

curvature,  static  curve    119 

curvature,  structural  curves,  122 

curvature,  superincumbent  weight,  125 

curvature,  suspension,  157 

curvature,  symptoms,  ;o7 

curvature,  thorax,  143 

curvature,  torsion,  116 

curvature,  treatment,  156 

curvature,  varieties.  117 

curvature  in  I'otl's  disease,  18 

curvature  in  torticollis,  697 
Leather  jacket,  69 
Lengthening  in  tumor  albus,  370 
Ligaments  in  club-foot,  453 
Limp  in  lateral  curvature,  115 
Lipomatous  muscular  atrophy,  600 
Little's  club-foot  appliance,  480. 

disease,  583 
Local  applications  in  joint  disease,  251 
Localization  of  tuberculous  joint  disease, 
•    240 
Loose  bodies  in  the  knee-joint,  406 

bodies,  pathology  of,  212 

cartilage  of  hip-joint,  365 
Lordosis,  194 

Lorenz,  anatomical   changes  in    lateral  cur- 
vature,   137 

apparatus  for  correction  of  lateral  cur- 
vature, 178 
Lumbar  abscess,  31 

Macewen's  operation  for  knock-knee,  667 
Malignant  disease  of  hip,  365 

disease  of  spine,  46,  199 
Malpositions  of   limb   in   hip  disease,    267, 

327     . 
Mechanics  of  standing,  760 
Mechanical  treatment  of  lateral  curvature, 
165 
correction  of  club-foot,  463 
appliances  in  lateral  curvature,  173 
Mental  impairment  in  spastic  paralysis,  583 

iinpairment  in  hemiplegia.  5S0 
Metatarsalgia,  759 
Metatarso-phalangeal    articulation,    disease 

of,  427 
Methodical  correction  in  lateral  curvature, 

177^ 
MoUiere's  operation  in  infantile  paralysis, 

577 
Morbus  coxre  senilis,  362 
Mortality  in  hip  disease,  295 
Morton's  club-foot  stretcher,  485 

affection,  759 
Mus  articulorum,  406 
Muscular  pseudo-hvpertrophy.  600 

fixation  in  tumor  albus,  370 

fixation  in  hip  disease,  265 

Neuromimesis,  see  Functional  Affections 
Night  cries  in  hip  disease,  264,  326 
Nodosity  of  joints,  225 
Non-deforming  club-foot,  746  • 
Norton's  operation  for  webbed  fingers,  535 


78o 


GENERAL  INDEX. 


Oblique  seat  in  lateral  curvature,  i66 
Obstetrical  paralysis,  592 
Ogston's  operation  for  knock-knee,  668 
Osteoclasis  in  bow-legs,  684 

in  hip  disease,  320 

in  infantile  paralysis,  577 

in  knock-knee,  670 
Osteoclast  of  Rizzoli,  6S4 

of  Colin,  686 
Osteotomy,  accidents  in,  665 

in  bow  legs,  687 

in  hip  disease,  330 

in  infantile  paralysis,  577 

for  knock-knee,  664 
Osteo-arthritis,  225 
Osteo-myelitis,  acute  infectious,  229 
Ostitis  deformans,  616 

pathology  of,  214 

syphilitic,  224 

traumatic,  229 

tuberculous,  214 

Painful  affection  of  foot,  759 
Palmar  fascia  contraction,  715 
Pain  in  hip  disease,  262,  287 

in  tumor  albus,  370 
Paralysis,  cerebral,  5 78 

infantile,  538 

of  Pott's  disease,  21 

of  Pott's  disease,  prognosis,  51 

of  Pott's  disease,  treatment  of,  95 

of  rickets,  621 
Paralytic  curvature  of  spine,  120 
Paraplegia  dolorosa,  200 
Patella,  dislocation  of,  414 

rupture  of  tendon  of,  416 
Pathology  of  joint  disease,  202 

of  hip  disease,  255 

of  tumor  albus,  366 

of  lateral  curvature,  134 

of  Pott's  disease,  i 
Pelvic  abscess  in  hip  disease,  325 
Pelvis,  distortion  of,  in  lateral  curvature,  139 
Peri-articular  joint  disease,  229 

symptoms  in  hip  disease,  271 
Perineal  bands,  312 

crutch  in  hip  disease,  323 
Periostitis  of  hip,  364 

Permanent  tetanus  of  the  extremities,  583 
Pes  arcuatus,  752 

cavus,  752 

cavus.  treatment,  753 

planus,  728 
Phalangeal  articulation,  diseases  of,  448 
Phelps'  fixation  appliance,  306 

operation  in  club-foot,  482 
Physiological  curves  of  spine,  122,  184 
Pigeon  breast,  20 1 
Plantar  fascia,  division  of,  474 
Plaster  jackets,  62 

of  Paris    spica  in  hip  disease,  302 
Poliencephalitis,  590 
Poliomyelitis,  acute  anterior,  538 
Porencephalus,  589 
Posterior  torticollis,  694 
Post-hemiplegic  disorders  of  movement,  581 


Pott's  disease,  i 

disease,  abscess  in,  30 
disease,  abscess,  treatment  of,  89 
disease,  adjustment  of  brace,  87 
disease,  antero-posterior  supports,  73 
disease,  appliances,  61 
disease,  attitude  in,  12 
disease,  braces  in,  72 
disease,  cause  of  death,  48 
disease,  condition  of  pupil  in,  20 
disease,  constitutional  treatment,  100 
disease,  definition,  1 
disease,  deformity,  25 
.     disease,  deformity  of  chest,  29 
disease,  diagnosis,  35 
disease,  diagnosis  of  abscess,  40 
disease,  differential  diagnosis,  42 
disease,  etiology,  9 
disease,  faulty  appliance,  86 
disease,  felt  jacket,  68 
disease,  frequency,  10 
disease,  general  condition,  34 
disease,  head  rests,  79,  80 
disease,  history,  i 
disease,   laminectomy,  97 
disease,  leather  jacket,  69 
disease,  localization,  10 
disease,  methods  of  treatment,  54 
disease,  mortality,  47 
disease,  objection  to  steel  supports,  817 
disease,  occurrence,  9 
disease,  operative  treatment,  96 
disease,  pain,  18,  38 
disease,  paralysis,  21 
disease,  paralysis,  pathology  of,  6 
disease,  paralysis,  recovery  in,  51 
disease,  paralysis,  treatment  of,  95 
disease,  patency  of  spinal  canal,  6 
disease,  pathological  anatomy,  i 
disease,  plaster  jackets,  62 
disease,  prehistoric  specimen,  2 
disease,  principles  of  treatment,  54 
disease,  prognosis,  47 
disease,  psoas  contraction,  treatment  of, 

94 
disease,  recession  of  deformity,  29 
disease,  recovery,  50 
disease,  recumbency   in  treatment  of, 

54 

disease,  silicate  bandages,  67 

disease,  summary  of  treatment,  loi 

disease,  suspension  in,  60 

disease,  symptoms,  12 

disease,  Taylor  brace,  75  . 

disease,  Thomas  collar,  82 

disease,  treatment,  52 

disease,  wire  collar  in,  83 

disease,  wry  neck  in,  44 
Prevention  of  lateral  curvature,  150 
Prognosis  of  hip  disease,  292 

in  tumor  albus,  374 
Progressive  muscular  atrophy,  606' 

muscular  atrophy,  symptoms,  607 

muscular  atrophy,  treatment,  608 
Protection  in  hip  disease,  320 

in  joint  disease,  253 


CliNI'lRA  L    INI)  liX. 


781 


Protection    in   treatment    of    liinior    albiis, 

375 
Pseudo-liypertrophic  paralysis,  Ooo 

paralysis,  dia^jnosis,  (io\ 

paralysis,  ]3atholojjy,  601 

paralysis,  etioloj^y,  600 

paralysis,  symptoms, Ooi 

paralysis,  treatment,  O05 
Psoas  abscess,  30 

contraction,  treatment  of,  94 

Rachitis  (see  rhachilis),  Or2 

Real  shortenintr,  282 

Reclinintj  couches  in  lateral  curvature,  i8l 

Recumbtncy  in  I'ott's  disease,  54 

"  Reel  "  foot,  450 

Reeve's  operation  in  knock-knee,  669 

Regressive  paralysis,  538 

Relapses  in  club-foot,  501 

in  hip  disease,  323 
Repair  of  divided  tendons,  475 
Resection,  see  Excision 

of   quadriceps   extensor   tendon  in   in- 
fantile paralysis,  576 
Retro-pharyngeal  abscess,  32 
Rhachitic  curvature  of  spine,  42 

deformity  of  arm,  628 

head,  623 

hand,  623 

kyphosis,  632 

lateral  curvature,  118 

spine,  626 
Rhachitis  (see  Rickets),  612 
Rheumatic  gout,  pathology  of,  225 
Rheumatism  of  the  spine,  191 
Rheumatoid  arthritis,  47,  225 
Rickets,  612 

and  syphilis,  620 

attitude,  627 

changes  in  bones,  622 

deformities  of  chest,  625 

deformities  of  spine,  626 

deformity  of  arm,  628 

deformity  of  hip,  628 

deformity  of  pelvis,  628 

delayed  dentition  in,  630 

diagnosis,  629 

differential  diagnosis,  630 

etiology,  614 

geographical  distribution,  617 

heredity  in,  617 

hydrocephalus,  625 

kyphosis,  626 

lordosis,  627 

occurrence,  614 

paralysis  in,  621 

pathological  anatomy,  613 

prognosis,  633 

scoliosis,  627 

symptoms,  621 

treatment,  634 

of  adolescence,  615 
Rigidity  of  spinal  column  in  Pott's  disease, 

35 
Rizzoli's  osteoclast,  684 
Round  shoulders,  188 


Sack()-<:oc(;y(;kai,  disease,  449 

Sacro-coxitis,  445 

Sacro-iliac  disease,  445 

Sarcoma  of  the  spine,  199 

Sayre's  appliance  for  talipes  ctiuinus,  750 

hip  splint,  311 
Scapho-cuneiform  articulation,   disease  of, 

427  ^ 
Scarpa's  shoe,  479 

School  chairs  for  lateral  curvature,  153 
Scoliosis,  103 

in  rickets,  627 
Scrofulous  arthritis,  204 

disease  of  knee,  366 

joint  disease,  214 
Senile  coxitis,  363 

rickets,  615 
Sex  in  tuberculous  joint  disease, 239 
Shat'ier's  appliance  for  club-foot,  471 

knee  splint,  379 

treatment  for  talipes  equinus,  749 
Shortening  after  excision  of  the  knee,  390 

in  hip  disease,  274,  281,  299,  337 

in  tumor  albus,  370 

real  and  apparent,  282 
Shoulder,  arthritis  deformans  of,  431 

Charcot's  disease,  432 

joint,  excision  of,  433 

ostitis  of,  430 

periarthritis  of,  431 

synovial  cysts,  432 

synovitis  of,  429 
Sleep,  attitude  in,  154 
Spinal  accessory  nerve  in  torticollis,  710 
Sterno-clavicular  joint,  diseases  of,  449 
Stromeyer's  club-foot  appliance.  480 
Strumous  arthritis  of  knee,  366 
Spastic  paralysis,  574,  582 

paralysis,  gait  in,  583 

paralysis,  symptoms  of,  582 
Spinal  paralysis,  538 

spastic  paralysis,  5S5 
Spine,  angular  curvature,  i 

carcinoma,  199 

functional  affections  of,  761,  764 

lateral  curvature,  103 

malignant  disease,  199 

physiological  curves,  1S4 

rheumatism  of,  191 

sarcoma,  igq 

tenderness  of,  200 

weakness,  196 
Splay  foot,  727 
Spondylitis  deformans,  1 91 
Spondylolisthesis.  196 

diagnosis.  19S 

etiology,  19S 
Spontaneous  recovery-  in  hip  disease,  295 
Spurious  valgus.  72S 
Standing,  mechanics  of,  760 
Static  curvature  of  spine,  119 
Sternal  articulation,  disease  of.  449 
Stiffness  in  hip  disease,  265,  27S 
Stocking  extension  in  hip  disease,  315 
Subluxation  in  knee-joint  disease,  371 
Subtrochanteric  osteotomy,  332 


782 


GENERAL  INDEX. 


Supernumerary  fingers,  529 
Suppurative  hip  disease,  mortality,  294 

hip  disease,  prognosis,  294 
Suspension  in  lateral  curvature,  157 
Symphysis  pitbis,  disease  of,  449 
Syndactylism,  534 

operation  for,  534 
Synovia,  203 
Synovial  membrane,  anatomy,  202 

membrane,  diseases  of,  202 
Synovitis  of  ankle  joint,  418 

chronic  purulent,  pathology  of,  206 

chronic  serous,  pathology  of,  204 

dry,  206 

hyperplastica  pannosa,  205 

of  shoulder,  429 
Syphilis  in  joint  disease,  241 
Syphititic  disease  of  hip,  364 

ostitis,  224 

Talipes  calcaneus,  751 

calcaneus,   Nicoladoni's  operation,  576 

calcaneus,  operative  treatment,  751 

calcaneus,  Willett's  operation,  575 

equino-varus,  450;  see  also  Club-foot 

equinus,  743 

equinus,  mechanical  treatment,  749 

equinus,  operative  treatment,  750 

equinus,  Sayre's  treatment,  750 

equinus,  Shaffer's  treatment,  746 

equinus,  treatment,  747 

valgus,   727 

valgus,  acquired,  728 

valgus,  congenital,  727 

valgus,  etiology,  728 

valgus,  operative  treatment,  742 

valgus,  rhachitic,  728 

valgus,  static,  728 
Taylor  brace  for  Pott's  disease,  75 

hip  splint,  310 
Taylor's  varus  shoe,  467 
Teething  palsy,  538 
Temperature  in  hip  disease,  276 

in  Pott's  disease,  35 
Temporo-maxillary  articulation,  disease  of, 

448 
Tenderness  of  spine,  200 
Tendo  Achillis,  section  of,  473 
Tenotomy,  473 

in  cerebral  paralysis,  596 

in  infantile  paralysis,  574 
Tetanoid  pseudo-paraplegia,  583 
Thomas'  knee  splint,  376 

splint  for  hip-disease,  303 

treatment  of  flat-foot,  741 
Thorax,  distortion  of,  200 

in  lateral  curvature,  143 
Tibialis  anticus,  section  of.  474 

posticus,  section  of,  473 
Toes,  contraction  of,  536 

deficiencies  of,  532 

deformities  of,  753,  758 

hypertrophy  of,  532 

supernumerary,  529 

webbed,  533 
Torsion  in  lateral  curvature,  135 


Torticol.is,  691 

Buckminster    Brown's   appliance    for, 

703 

compensatory  form,  693 

congenital,  692 

diagnosis,  699 

etiology,  691 

intermittent  form,  698,  709 

lateral  curvature  in,  697 

mechanical  treatment,  701,  704 

myotomy  in,  706 

nerve  stretching,  710 

oculaire,  691 

open  incision,  706 

operative  treatment,  705 

pathological  anatomy,  694 

posterior,  694 

prognosis,  700 

resection  of  nerve,  710 

results  of  treatment,  707 

spastic  form,  693 

symptoms,  696 

tenotomy  in,  705 

treatment,  701 

varieties,  692 
Traction  by  weight  and  pulley,  315 

in  hip-disease,  307 

in  joint-disease,  253 

in  tumor  albus,  379 

splints  in  hip-disease,  310  • 

straps  in  hip-disease,  314 
Traumatic  ostitis,  229 
Treatment  of   joint-disease,   principles  of, 

251 

of  hip-disease,  301 

of  tumor  albus,  374 
Trephining  in  cerebral  paralysis,  597 

in  hip-disease,  354 
Tubercular  bacilli,  in  joint-disease,  220 

disease  of  knee,  366 

infection,  following  hip-disease,  346 
Tuberculosis  of  joints,  214 
Tuberculous  ostitis,  214 
Tumor  albus,  abscess,  372 

albus,  amputation,  396 

albus,  ankylosis,  384 

albus,  arthrectomy,  395 

albus,  atrophy,  369 

albus,  clinical  history,  368 

albus,  conservative  treatment,  375 

albus,  counter-irritation,  378 

albus,  diagnosis,  372 

albus,  differential  diagnosis,  373 

albus,  excision,  387 

albus,  fixation,  375 

albus,  fixation  bandages,  383 

albus,  forcible  straightening,  3S1 

albus,  heat,   370 

albus,  lameness,  370 

albus,  lengthening,  370 

albus,  muscular  fixation,  370 

albus  of  the  knee,    366 

albus,  operative  treatment,  388 

albus,  pain,  370 

albus,  pathology,  366 

albus,  prognosis,  374 


(iENI'lRAL    INDEX. 


1^1 


Tumor  albus,  protection,  375 

albiis,    results   of    conservative    treat- 
ment, 389 

albus,  shorteninjj,  369 

albus,  subluxation,  371 

albus,  summary  of  treatment,  397 

albus,  traction,  379 

albus,  treatment  of  abscesses,  387 

albus,  treatment  of  complications,  378 

albus,  treatment  of  flexion,  379 

albus,  treatment  of  subluxation,  380 
Tumors  of  fingers  and  toes,  536 

of  joints,  227 

Unii,ATF.RAL  atrophy  and  hypertrophy,  712 


Vance's  splint  in  hip-disease,  302 

Wry  neck,  691 

Wrist,  diseases  of,  441 

Wire  cuirass  in  hip-disease,  305 

Willet's  operation  for  talipes  calcaneus,  575  4 

Whitman's  valfjus  plate,  740 

White  swellinji,  366 

swelling,  pathology  of,  206 
Weight,  table  of,  149 
Webbed  fingers  and  toes,  533 

fingers,  operation  for,  534 
Weak  ankles,   733 

spines,  196 
Water  on  the  knee,  399 


Valgus  sole  plate,  740 


Zeller's  operation  for  webbed  fingers,  535 


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